BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, JALANDHAR.

 Complaint No.192 of 2019

      Date of Instt. 30.05.2019

                Date of Decision: 23.07.2024

Shadi Lal Dhir aged about 68 years S/o Sh. Sardari Lal, resident of 143/A, Adarsh ​​Nagar, Jalandhar.

..........Complainant

Versus

1.       Apollo Munich Health Insurance Company Limited, through its        Manager/Authorized Representative, Registered Office at Apollo Hospitals Complex, Jubille Hills, Hyderabad-500033, Andhra   Pradesh.

2.       Apollo Munich Health Insurance Company Limited, through its        Manager/Authorized Representative, Branch Office at First          Floor, Satnam Complex, BMC Chowk, Jalandhar.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before:        Dr. Harveen Bhardwaj             (President)

                   Smt. Jyotsna                            (Member)

                   Sh. Jaswant Singh Dhillon       (Member)   

Present:       Sh. Gurcharan Singh, Adv. Counsel for Complainant.

                   Sh. Vikas Gupta, Adv. Counsel for OPs.

Order

Dr. Harveen Bhardwaj (President)

1.                The instant complaint has been filed by the complainant, wherein it is alleged that the complainant got insured himself and his wife Mrs. Satyawati Dhir from 22.11.2013 to 21.11.2014 and being insured periodically renewed the same in time (from 2013 to 2019) without any break. The policy was issued after the company has examined the complainant from Balaji Hospital, Ashok Nagar, Jalandhar, before issuance of policy. The complainant had never availed any claim till date. Unfortunately, the complainant was not keeping good health and was hospitalized in Shri Nath Kidney Centre, Jalandhar and supportive treatment as per advice of Dr. Ajay Marwaha was given to the complainant. The complainant was admitted in Shri Nath Kidney Centre, Jalandhar on 27-01-2018 and discharged on 03-02-2018 and after discharge from the hospital, the complainant lodged the claim with the opposite parties on dated 17.02.2018 bearing claim ID no.710943 as the complainant was having medical/health insurance policy with the OPs. The complainant even completed all the requisite formalities and even submitted all the documents as per the requirement of the OPs. Despite furnishing the requisite documents, the OPs have not released the claim of the complainant and sent letter dated 26.02.2018 to the complainant regarding the requirement of additional documents. The documents which were available with the complainant were supplied in original to the OPs accordingly. The complainant has not retained the copy of those documents. Even otherwise, the claim is payable after waiting period of 36 months from the date of first policy of the complainant. The policy of the complainant is renewed without any break till the present claim. The claim of the complainant is covered under the policy. To the utter surprise of the complainant, even after furnishing the requisite documents as demanded by the OPs, the claim of the complainant was arbitrarily repudiated. The OPs have practiced unfair trade practice with the complainant and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to release the total amount of Rs.3,02,585/- i.e. claim amount Rs.91,585/- alongwith interest @ 18% per annum. Further, OPs be directed to pay Rs.1,00,000/- as compensation for causing mental tension and harassment to the complainant and Rs.11,000/- as litigation expenses.

2.                Notice of the complaint was given to the OPs, who filed reply and contested the complaint by taking preliminary objections that the present complaint is frivolous, vexatious and devoid of merits and hence, the same is liable to be dismissed with heavy cost. It is further averred that the complainant has not approached this Forum with clean hands. The complainant has suppressed various material facts in the present complaint. Hence, the present complaint is liable to be dismissed on this ground only. It is further averred that there is no deficiency in service or negligence or unfair-trade practice on the part of answering OP which brings the present case adjudicable before this Forum under Consumer Protection Act. It is further averred that the present complaint is not maintainable under any provision of law is liable to be dismissed with heavy cost. It is admitted that the complainant got himself insured under health policy from the OP since 2013, which was renewed every year till 2018 and the factum with regard to admission of the complainant in Shri Nath Kidney Centre on 27.01.2018 is admitted, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.

3.                Rejoinder to the written statement filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied the allegations raised in the written statement.

4.                In order to prove their respective versions, both the parties have produced on the file their respective evidence.

5.                We have heard the arguments from learned counsel for the respective parties and have also gone through the case file very minutely.

6.                It is admitted that the complainant got himself insured under health policy from the OP since 2013, which was renewed every year till 2018 and the last policy was valid from 22.11.2018 to 21.11.2019. The complainant has proved on record the insurance policies Ex.C-1 to Ex.C-6 and the terms of the policy Ex.C-7. The complainant has alleged that he got admitted in Shri Nath Kidney Centre on 27.01.2018 and was discharged on 03.02.2018. The claim was lodged, which has been proved as Ex.C-8/OP-3. As per submission of the complainant, the complainant has provided the relevant documents required by the OPs, vide Ex.C-9 and Ex.C-10, whereas the contention of the OPs is that despite the reminders for number of times, the complainant has failed to provide the documents. The OPs have relied upon the letter Ex.OP-4, vide which they have demanded the documents, which were supplied by the complainant, vide Ex.OP-5 and Ex.OP-6, but thereafter, the OP again put query, vide letter Ex.OP-7 and Ex.OP-8 for furnishing the documents, but as per allegations of OP the complainant has failed to provide them the documents and ultimately, the claim of the complainant was rejected, vide Ex.OP-9 to Ex.OP-11. Ex.OP-11 shows that the claim of the complainant was rejected due to non submission of the documents by the complainant. The detail of required documents has been mentioned in Para No.2 of the rejection letter Ex.C-11/OP-11. The OPs have demanded all investigation and follow up record prior to current hospitalization as it has been alleged by the OPs that the complainant was known case of DM, HTN and Acute Kidney Injury, therefore, claim was rejected on this ground only. When the claim has not been decided on merits, in such circumstances, the complainant is directed to furnish the documents/information, which was required by the OPs for settlement of the claim within 10 days from the date of receipt of the copy of order, if these documents are in possession of the complainant. The OPs cannot force the complainant to produce the documents as per law laid down by the Hon’ble Supreme Court, in a case titled as ‘Gurmel Singh v. National Insurance Co. Ltd.’, 2022 SCC OnLine SC 666, decided on 20.05.2022. The OPs themselves can verify from the doctor, if need be after enquiring from the complainant. The OPs are directed to settle the claim of the complainant within 25 days from the date of receipt of the copy of order, failing which the OPs will be liable to pay a compensation of Rs.20,000/- to the complainant. It is further ordered that if the complainant is not satisfied with the settlement of the claim made by the OPs, then he is at liberty to file a fresh complaint. Thus, the complaint of the complainant is disposed of. This complaint could not be decided within stipulated time frame due to rush of work.

7.                Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated          Jaswant Singh Dhillon    Jyotsna               Dr. Harveen Bhardwaj      

23.07.2024         Member                          Member           President