FINAL ORDER/JUDGEMENT
SHRI SWAPAN KUMAR MAHANTY, PRESIDENT
This is an application u/s.35 of the C.P. Act, 2019.
Case of the complainant is that he had obtained Mediclaim Policy being No. 111200/11121/AA00028207-03 for the period from 22.02.2011 to midnight of 21.02.2011 from the OP Apollo Munich Health Insurance Company Ltd. The said policy was renewed till the midnight of 21.02.2012. Complainant ported the said policy to Max Bupa Health Insurance for the period from 22.02.2013 to 21.02.2014. Complainant again ported the policy to the OP with an assurance to entitle all benefits of the previous policy from its date of inception. During existing of the said policy, complainant was admitted to Belle View Clinic for medical treatment and also incurred Rs. 1,60,812/-. Complainant submitted claim form along with its related documents but the OP repudiated claim on the ground that treatment related to Psychiatric Disease which fail under Psychiatric/Mental disorder. Fining no other way out, the complainant filed the present consumer complaint.
Despite of service of notice, OP did not turn up to contest the case. As such, the case has proceeded ex parte against the OP.
Complainant Mr. Vijay Kumar Singhania has filed his evidence on affidavit. Complainant relied upon the complaint petition along with its annexure thereto. We have gone through the evidence as well as documents on record.
On perusal of the Annexure-A, it appears to us that complainant obtained Mediclaim Policy being No. 150100/11119/AA00028207 for a total insured sum of Rs. 15,00,000/- from the OP and the said policy was valid from 22.02.2014 to 21.02.2015.
It is significant to mention here that the subject policy was continues coverage of 05 years (Annexure-B). The subject policy was ported from Max Bupa. On perusal of the Annexure-C, we find that complainant was admitted to Belle Vue Clinic on 04.05.2017 with intermittent loss of consciousness and recurrent vomiting diseases and discharges on 08.05.2017.
No doubt, complainant submitted claim form along with all related documents of treatment to the OP for reimbursement the claim in terms of VC XII (I) of the policy. There is no evidence and/or document on the part of the OP to show that complainant having any psychiatric/Mental disorder prior to obtaining Mediclaim Policy. It is not in dispute that the complainant was hospitalized for treatment during currency of the policy and spent Rs. 1,68,812/-. When the OP failed to establish that complainant was suffering from Psychiatric/Mental disorder prior to obtaining policy, thus repudiation of claim is illegal.
Regard being had to the entire facts and circumstances of the case coupled with evidence and documents on record, we are of the opinion that there is deficiency in service and unfair trade on the part of the OP. Thus, the complaint is allowed with following directions:-
- OP/Insurer is directed to pay Rs. 1,68,812/- to the complainant within a period of 60 days.
- OP/Insurer is further directed to pay simple interest at the rate of 5 P.A. to the complainant from the date of repudiation within the specified period.
- OP/insurer is also directed to pay Rs. 5,000/- as litigation cost to the complainant within the specified period.
A copy of the judgment be provided to the parties as mandated by the Consumer Protection Act. The judgment be uploaded forthwith on the website of the commission for perusal of the parties.
