Chandigarh

DF-I

CC/631/2016

Rajeev Garg - Complainant(s)

Versus

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

Sanjeev Goyal

21 Aug 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

 

 

                               

Consumer Complaint No.	:	CC/631/2016
Date of Institution	:	09/08/2016
Date of Decision	:	21/08/2018

 

Rajeev Garg S/o Shri Roshan Lal, R/o H.No.346, Phase-2, Mohali.

…..Complainant

V E R S U S

1.     Apollo Munich Health Insurance Co. Limited, Branch Office 4^th Floor, SCO 50-51, Sector 34-A, Chandigarh – 160022, through its Branch Manager.

2.     Apollo Munich Health Insurance Co. Limited, Head Office 10^th Floor, Tower-B, Building No.10, DLF Cyber City, DLF City Phase-II, Gurgaon (Haryana) – 122002, through its Managing Director.

……Opposite Parties

 

CORAM :	MRS.SURJEET KAUR	PRESIDING MEMBER
	SURESH KUMAR SARDANA	MEMBER

 

                                                                       

ARGUED BY	:	Sh. Gaurav Bhardwaj, Counsel for Complainant.
	:	Sh. Pawan Kumar, Vice Counsel for Sh. Nitin Thatai, Counsel for OPs.

Per Suresh Kumar Sardana, member

1.         The facts of the consumer complaint, in brief, are that lured by the lucrative benefits projected by the Agent of the Opposite Parties, Complainant purchased Easy Health Individual Standard Policy for the period 23.02.2010 to 22.02.2011. Subsequently,  the Complainant got renewed the said Policy for the period 2011-12, 2012-13, 2013-14, 2014-15 and 2015-16. In Jan. 2016, the Complainant fell ill and was taken to Garg Diabetes and Heart Care Centre, Mohali in an emergency condition. He remained admitted in the said Hospital from 11.01.2016 to 17.01.2016 and spent an amount of Rs.1,21,673/- on his treatment. After discharge from the Hospital, the Complainant submitted all the documents required for releasing the claim along with the original medical bills, however, vide letter dated 12.04.2016 the Opposite Parties repudiated the claim of the Complainant. With the cup of woes brimming, the Complainant has filed the instant consumer complaint, alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on the part of the Opposite Parties.
2.         Opposite Parties filed their joint written statement admitting the basic facts of the case. It has been pleaded that the Hospital where the Complainant was admitted does not fulfill the criteria of the Hospital as per the definition mentioned in the Policy and therefore the claim was rightly repudiated under Section VIII definition 22 of the Policy. Pleading that there is no deficiency in service or unfair trade practice on their part, Opposite Parties have prayed for dismissal of the complaint.
3.         The parties led evidence in support of their contentions.
4.         We have gone through the entire record and heard the arguments addressed by the Ld. Counsel for the Parties.
5.         In the light of the contentions advanced before us, the following question arise for our consideration:-

[i]     Whether the Opposite Parties were justified in repudiating the claim of the Complainant vide repudiation letter dated 12.04.2016 (C-7)?

                The answer to the question posed is in negative.

6.         The prevalence of the policy i.e. Easy Health Individual Standard Plan at the time when the Complainant fell ill and remained hospitalized in Garg Diabetes and Heart Care Centre, Mohali has not been disputed before us at all. Per record, it is evident that the Complainant spent an amount of Rs.1,21,673/- on his treatment.        
7.         The Opposite Parties repudiated the claim of the Complainant on the ground that the Garg Diabetes and Heart Care Centre from where the Complainant took the treatment does not fulfill the criteria of a Hospital.
8.         We have thoroughly scanned the Easy Health Individual Standard Policy (Annexure C-1) issued by the Opposite Parties. The Opposite Parties in the said policy issued the list of 160 Hospitals under which the medical reimbursement/treatment was not allowed. However, the Opposite Parties did not provide any list of the empaneled Hospitals in the said Policy. Moreover, there is no condition in the Policy that the Complainant cannot get treatment from the non-network hospital. Thus, it is legitimately proved that the Opposite Parties have illegally rejected the claim of the Complainant on false and flimsy grounds and they are liable to pay the claimed amount to the Complainant.     
9.         In view of the foregoings, we are of the opinion that the present Complaint must succeed. The same is accordingly partly allowed. Opposite Parties are, jointly and severally, directed as under:-

 

[a]    To pay the claim amount of Rs.1,21,673/- to the Complainant along with interest 9% per annum from the date of repudiation of the claim (Annexure C-7) i.e. 12.04.2016, till realization.

[b]    To pay Rs.25,000/- as compensation on account of deficiency in service and causing mental and physical harassment to the Complainant; 

[c]    To pay Rs.10,000/- 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 amount mentioned in sub-para [a] above from the date of repudiation of the claim i.e. 12.04.2016, till it is paid. The compensation amount as per sub-para [b] above, shall carry interest @12% per annum from the date of institution of this complaint, till it is paid, apart from cost of litigation as in sub-para [c].

 

11.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-
21/08/2018	[Suresh Kumar Sardana]	[Surjeet Kaur]
	Member	Presiding Member
Dutt”