Chandigarh

DF-I

CC/179/2015

Keshav Gupta - Complainant(s)

Versus

Apollo Munich Health Insurance Co. Ltd. - Opp.Party(s)

Tejwinder Singh Hundal

07 Dec 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

============

Consumer Complaint  No	:	CC/179/2015
Date  of  Institution	:	23/03/2015
Date   of   Decision	:	07/12/2015

 

 

 

 

 

Keshav Gupta son of Sh. Ram Lal Gupta, resident of House No.1290, Sector 44-B, Chandigarh.

……….. Complainant.

VERSUS

 

1.   Apollo Munich Health Insurance Co. Limited, having its registered Office at Apollo Hospitals Complex, Jubilee Hills, Hyderabad, through its Director.

 

2.   Apollo Munich Health Insurance Co. Limited, having its local office at 4^th floor, SCO 50-51, Sector 34-A, Chandigarh – 160022, through its Manager.

 

……….. Opposite Parties 

 

BEFORE:   MRS.SURJEET KAUR             PRESIDING MEMBER

          SH. SURESH KUMAR SARDANA     MEMBER

 

For Complainant	:	Ms. Ana Bansal, Advocate.
For Opposite Parties	:	Sh. Nitin Thatai, Advocate.

 

PER SURESH KUMAR SARDANA, MEMBER

 

         

1.      Tersely, the facts and material, culminating in the commencement, relevant for the disposal of the instant Consumer Complaint and emanating from the record are that, the Complainant purchased a Medical Insurance Policy No. 110300/11052/1000414107 from the Opposite Parties. During the currency of the policy, while playing Squash, the Complainant got his ankle twisted and consulted an Orthopedic Surgeon, but did not get any relief therefrom. Thereafter, he consulted a doctor at Columbia Asia Hospital, Patiala, who advised a Surgery (Ex.C-4). After receiving and going through the various documents sent by the aforesaid Hospital, on behalf of the Complainant, and thereby considering his past medical history, including that of Epilepsy Disorder, the Opposite Parties sent authorization letter dated 14.08.2014 to the Hospital for the treatment and guarantee of payment (Ex.C-10). Based on this authorization, the Complainant proceeded with surgery and got admitted on 16.08.2014 and was operated upon the same day. He was discharged on 17.08.2014, but after payment of Rs.66,687/- as Opposite Parties refused to accept the cashless hospitalization services, without giving any opportunity to the Complainant (Ex.C-12). It has been stated that the aforesaid acts of the Opposite Parties, amounted to deficiency, in rendering service, as also indulgence into unfair trade practice. When the grievance of the complainant, has not been redressed, left with no alternative, the present complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter to be called as the Act only), has been filed before this Forum, seeking various reliefs.

 

2.      Notice of the complaint was sent to Opposite Parties seeking their version of the case.

 

3.      Opposite Parties in their joint reply, while admitting the factual matrix of the case have pleaded that the Complainant was having prior medical history of Seizures since childhood and has also taken treatment for the same and further history of exploratory laparotomy for perforation peritonitis enteric fever and colostomy closure under GA was done 10 years back at the time of applying for the subject policy. The said fact was knowingly and deliberately suppressed by the Complainant which is against the fundamentals of the Law of Contract i.e. “uberrima fides” and therefore, the insurance contract is not binding upon the answering Opposite Parties. It has been admitted that the cashless pre-authorization was given by the Opposite Parties only to the extent of Rs.25,000/- to the Complainant, but the same was withdrawn after reconsidering the facts and due to non-supply of documents. Denying all other allegations Opposite Parties have prayed for dismissal of the complaint. 

 

4.      The Complainant also filed replication to the written statement filed by the Opposite Parties, wherein the averments as contained in the complaint have been reiterated and those as alleged in the written statement by the Opposite Parties have been controverted.

 

5.      Parties were permitted to place their respective evidence on record in support of their contentions.

 

6.      We have heard the learned Counsel for the parties and have also perused the record, along with the written arguments filed on behalf of both the sides. 

 

7.      Admittedly, the Complainant was covered under the “Easy Health Floater” medical insurance policy valid from 21.08.2013 to 20.08.2014. The Complainant had undergone Surgery on 16.08.2014 at Columbia Asia Hospital, Patiala. It is observed that the Complainant underwent surgery only after obtaining authorization for the treatment and the surgery vide authorization letter Ex.C-10. The procedure to avail cashless hospitalization facility procure is laid down in the terms and conditions of the insurance policy (Ex.C-2 at Page 36). The said procedure is reproduced herein below:-

 

“* for any planned hospitalization, kindly seek cashless authorization from your designated TPA atleast 48 hours prior to hospitalization.

 

*    TPA will check your coverage as per the eligibility and send an authorization letter to the provider. In case there is any deficiency in the documents sent, the same shall be communicated to the hospital within 6 hours of receipt of documents.

 

*    In case ailment/treatment is not covered under the policy a rejection letter would be sent to the provider within 6 hours.”

 

 

8.      In the instant case, the refusal by the Opposite Parties, to honour their obligation to pay for the treatment of the Complainant, after issuance of the authorization letter to the hospital for the treatment and guarantee of payment, was at a time when the Complainant had already undergone Surgery and was bed ridden and his family was made to run from pillar to post for arranging the finances required for the payment of the hospital bills. The denial of the legitimate claim of the Complainant, in these set of circumstances, to our mind, amounts to unfair trade practice and deficiency in service.

 

9.      In the light of above observations, we are of the concerted view that the present complaint of the Complainant deserves to succeed against the Opposite Parties, and the same is allowed, qua them. The Opposite Parties are, jointly & severally, directed:-

 

[a]  To pay Rs.66,687/- to the Complainant;

 

[b]  To pay Rs.30,000/- to the Complainant on account of deficiency in service, unfair trade practice and causing mental agony and harassment; 

 

[c] To pay Rs.15,000/- as cost of litigation;

 

10.      The above said order shall be complied within 30 days of its receipt by the Opposite Parties; thereafter, they shall be liable for an interest @12% per annum on the amounts mentioned in sub-para [a] & [b] above from the date of institution of this complaint, till it is paid, apart from cost of litigation as in sub-para [c] above.  

 

11.      Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

07^th December, 2015                                            

Sd/-

(SURJEET KAUR)

PRESIDING MEMBER

 

Sd/-

(SURESH KUMAR SARDANA)

MEMBER