Chandigarh

DF-I

CC/475/2015

Bhajan Singh - Complainant(s)

Versus

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

Anirudh Gupta

12 Feb 2016

ORDER

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

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

Consumer Complaint  No	:	475 of 2015
Date  of  Institution	:	28/7/2015
Date   of   Decision	:	12.2.2016

 

 

 

 

 

Bhajan Singh S/o Jalbir Singh r/o House No.3236/2, Sector 41, Chandigarh.

….Complainant

Vs.

 

1. Apollo Munich Health Insurance Co. Ltd. having its registered office at 2^nd &3^rd floor, Ilabs centre Plot No.404-405, Udyog Vihar Phase III, Gurgaon 122016 Haryana through its Manager.
2. Apollo Munich Health Insurance Co. Ltd. having its Branch office at SCO 50-51, 4^th floor, Sector 34A, Chandigarh 160022 through its Branch Manager.

…… Opposite Parties 

BEFORE:                                                                     PRESIDENT

MRS.SURJEET KAUR                             PRESIDING MEMBER

SH. SURESH KUMAR SARDANA           MEMBER

 

 

For Complainant	:	Sh. Anirudh Gupta, Advocate.
For OPs	:	Sh. Nitin Thatai, Advocate.

 

 

PER SURESH KUMAR SARDANA, MEMBER

 

 

 

                The facts, in brief, are that the complainant purchased a medi claim policy from the OPs for his parents covering the risk cover of Rs. 3 lacs for the period from 6.11.2014 to 5.11.2015 after paying a premium of Rs.23,228/-. The OPs issued policy No.11300/11051/AA0162284. The father of the complainant fell ill on 9.2.2015 and was admitted in JP Hospital, Yamuna Nagar for the period from 9.2.2015 to 13.2.2015 and incurred a total amount of Rs.24,705/- and thereafter again admitted from 16.2.2015 to 18.2.2015 and the again a sum of Rs.14,528/- was incurred by the complainant for the treatment.  The complainant sent the claim to the OPs alongwith the documents required by them. But they again and again demanded same documents, which they were supplied. Yet the Opposite Parties lingered on the claim of the complainant on one pretext or other.  Pleading deficiency on the part of the Opposite Parties the complainant has filed the instant complaint.

         

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 stated that prima facie no cause of action has arisen in favour of the complainant to file the present complaint as he failed to provide the mandatory documents asked for by the LPs vide letters dated 5.3.2015, 17.3.2015 and 30.3.3015 and 6.4.2015 and ultimately due to non receipt of the required documents the claim of the complainant was closed vide letter dated 17.4.2015. It is averred that the complainant on 1.4.2015 submitted a prescription dated 9.2.2015 of the treating hospital and as per the same insured Mr. Jalbir Singh was a case of cold and expectorant since 4 to 5 months. Pertinently this period 4 to 5 months is going beyond the date of proposal and also the same doctor has earlier given a certificate dated 8.3.3015 that patient was admitted with case of cough and expectorant of 2 months duration. So it is clear from the above that the treating doctor’s certificate dated 8.3.2015 is contrary to the prescription dated 9.2.2015 and also the duration of the ailment as mentioned in the prescription dated 9.2.2015 as 4 to 5 months was beyond the date of proposal which is 6.11.2014. It is averred that from the submitted document, discrepancies were observed in prescription and certificate given by the documents about the duration of chronic obstructive pulmonary disease (COPD).  In spite of number of letters written by the OPs the complainant failed to provide treating doctor certificate mentioning the duration of COPD with first consultation paper and past treatment record, therefore, the OPs have no alternative then to close the claim of the complainant. Denying all other allegations and stating that there is no deficiency in service or unfair trade practice on their part, Opposite Parties have prayed for dismissal of the complaint.

4.          The complainant has filed a rejoinder, wherein he has reiterated all the averments, contained in the complaint, and repudiated those, contained in the written version of Opposite Parties.

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 perused the record carefully.

 

7.          The main case of the complainant is about rejection of the medical claim by the OPs based on suppression of material facts when making a proposal for insurance by not declaring pre-existing disease.  It is observed that a panel of doctors of OPs have done many test before issuance of policy at Nanaksar Hospital on 18.11.2014 i.e. serum Bilirubium direct and indirect, total serum protein albumin, globulin, A/G ratio Alkaline Phosphatase, SGOT, SGPT, GGTP, Cratinine, Blood Urea, Uric Acid, HBsAg, HIV 1and 2, fasting blood sugar, routine urine and microscopic, lipid profile, haemogram, PSA, 2D color Doppler, Echo Cardiography of both the parents and one extra test of Ultrasound of Abdomen of the mother of the deponent.  All reports were found to be normal. If there was any pre-existing disease the same would have been detected in these test and the insurance company had the option to charge higher premium or to reject the insurance proposal.  The rejection of claim appears to be based on the statement of the father of the complainant made to the doctor that he was suffering from cold from 4-5 months, which cannot be said to be a feasible ground of rejection of the claim as there is no medical report/test placed on record by the OPs to fortify this statement of the complainant made to the doctor in a usual way.   Moreover, every person right from their childhood faces the problem of colds, which does not mean that the claim is to be rejected on non-declaration of the statement aforesaid. Had this been a chronic disease the same would been deduced by the doctors of the OPs who conducted various medical tests of the father of the complainant.  Hence rejection/closing the claim of the complainant on such ground is totally baseless and illegal. Thus, there is definitely deficiency on the part of the Opposite Parties in not indemnifying the claim of the complainant.

 

8.          In the light of above observations, we are of the concerted view that the Opposite Parties are found deficient in giving proper service to the complainant and having indulged in unfair trade practice. Hence, 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 and severally, directed  to:-

 

[a]     To pay the claim amount of Rs.39,233/- alongwith interest @9% p.a. from the date of  claim.

 

[b]     To make payment of Rs.10,000/- to the complainant towards compensation for causing mental and physical harassment.

 

[c]      To make payment of Rs.7,500/- to the complainant as litigation expenses.

 

 

9.          The above said order be complied with by the Opposite Parties, within 30 days from the date of receipt of its certified copy, failing which the amounts at Sr. No.[a] & [b] shall carry interest @12% per annum from the date of filing of the present Complaint, till actual payment, besides payment of litigation costs.

 

10.          The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

 

Announced

12.2.2016        

 (P.L. AHUJA)

PRESIDENT

Sd/-

 (SURJEET KAUR)

PRESIDING MEMBER

 

Sd/-

 (SURESH KUMAR SARDANA)

MEMBER