p DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Shilesh Gupta son of Shri Darshan Lal Gupta, resident of House No. 787, Sector 12, Panchkula – 134 109, Haryana.

                   --- Complainant

V E R S U S

1]      Apollo Munich Health Insurance Co. Limited, 4^th Floor, SCO No. 50-51, Sector 34-A, Chandigarh, through its Branch Manager.

2]      Apollo Munich Health Insurance Co. Limited, 10^th Floor, Building No.10, Tower-B, DLF City, Phase-II, DLF Cyber City, Gurgaon – 122 002, through its Director

---- Opposite Parties

BEFORE:      SH. LAKSHMAN SHARMA                    PRESIDENT

MRS.MADHU MUTNEJA                       MEMBER

                   SH.JASWINDER SINGH SIDHU             MEMBER

Argued By:             Complainant in person.

Sh. R.S. Dhull, Counsel for Opposite Parties.

PER JASWINDER SINGH SIDHU, MEMBER

1.                Briefly stated, the Complainant had taken one “Easy Health Floater Standard” Policy from the Opposite Parties, valid from 19.6.2011 to 18.6.2011, for a sum insured of Rs.5.00 lacs, covering himself, his wife - Smt. Sumedha Gupta and his two sons namely Krishiv Gupta (aged 5+ years) and Kavish Gupta (aged 3+ years), by paying a premium of Rs.11,580.40/-. During the currency of the above mentioned policy, Krishiv Gupta, aforesaid, developed some health problem and was advised surgery Adenoidectomy and Grommet Insertion in ears by Dr. Arun Mitra of Mitra Clinic Nursing Home, Ludhiana.  The Opposite Parties were duly informed regarding the same on 13.01.2012.  The surgery was performed on 11.02.2012 and the son of the Complainant was discharged in the same evening. The Complainant incurred a sum of Rs.11,000/- on the aforesaid surgery (summary & patient record at Annexure C-3 & C-4).  In order to claim reimbursement, the Complainant filled up the claim form, supplied by the Opposite Party, along with the requisite documents and medical reports and sent the same to its TPA. The Complainant claimed a sum of Rs.11,325/- from the Opposite Parties, which included Rs.11,000/- paid to the doctor for treatment & surgery and Rs.325/- towards the expenses incurred for purchasing medicines from the Chemist after the surgery. Thereafter, the Opposite Parties kept on demanding certain documents from the Complainant, time and again, which were duly supplied by the Complainant, so that his claim could be cleared expeditiously. However, after protracted correspondence exchanged by the Complainant with the Opposite Parties, on 18.05.2012, he received one SMS from LM-FHPTPA, arbitrarily declining his claim. Thereafter, on 26.05.2012, the Complainant received an e-mail informing that the claim had been repudiated on the ground that “as per the submitted documents, the hospital where the member was admitted does not fulfill the criteria of a hospital as per the definition mentioned in the policy. Hence, we regret to inform you that your claim is repudiated under Sec.8) Def-7 of the policy”. The Complainant claims that the Opposite Parties have misconstrued the policy wordings, to repudiate his genuine claim, in order to escape their liability. Hence, this complaint.      

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

3.                Opposite Party No.1 & 2, in their joint reply, while contesting the claim of the Complainant have mentioned that at the time of receiving the proposal form from the Complainant, for the policy in question, the same was accepted subject to policy terms and conditions (R-1 & R-2). It is also claimed that as per the terms & conditions of the policy, it was required that the Complainant would provide all necessary documents to the T.P.A. within 15 days of the request or the insured person’s discharge from the hospital. While submitting such claim, as required in Sec.7 of the policy that all original bills, reports, precise diagnosis of the treatment, for which the claim is made and other documents were required to be submitted to the company. In the present case, such requirements were not met by the Complainant, for settling claim, for the reasons best known to him alone. The Opposite Parties also sent a reminder dated 2.3.12 (R-4) but the Complainant failed to meet the deadline for such documentation. The Opposite Parties have also claimed that they tried to verify the claim from the treating hospital and it was revealed that the treating hospital does not conform to the criteria of a hospital as defined in the policy. As per the certificate dated 7.5.12 issued by Mitra Clinic Nursing Home, Ludhiana the hospital was just 05 bedded as against the number prescribed in the policy also that it is a general day care (R-5). The Opposite Parties defending their action of repudiation of the claim of the Complainant through their letter dated 19.5.2012 have held their ground. While pleading that there was no deficiency in service on their part, the Opposite Parties pray for dismissal of the complaint.   

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

5.                We have heard the Complainant in person and learned counsel for the Opposite Parties and have perused the record.

6.                The Complainant having subscribed for health insurance cover from the Opposite Parties for his family which included his wife and two sons by paying a premium of Rs.11,580/-. During the currency of this policy, which was valid from 19.6.2011 to 18.6.2012, the elder son of the Complainant master Krishiv Gupta developed a health problem. On diagnosis the treating doctor advised surgery of Adenoidectomy and Grommet Insertion in the ears. The Complainant duly intimated about the said surgery on 13.1.2012 and in reply to this, an intimation I.D. 12277 was conveyed on 16.1.2012. Complainant’s son was operated upon 11.2.2012 and was discharged on the same day in evening after the treatment. The Complainant had submitted all the required documents with the designated TPA at their Hyderabad office.  The Complainant had claimed a sum of Rs.11,325/- including an amount of Rs.11,000/- paid to the doctor for treatment and surgery and Rs.325/- for purchasing medicines. Even on subsequent occasion, the documents asked for too were procured and sent to the TPA, for processing of the claim. The Complainant thereafter, an SMS of his repudiation of the claim, and subsequently, he received an e-mail informing him about the repudiation of the claim lodged with them, on the following ground:-

“As per the submitted documents, the hospital where the member was admitted does not fulfill the criteria of a hospital as per the definition mentioned in the policy. Hence, we regret to inform you that your claim is repudiated under Sec.8) Def-7 of the policy”. 

                   The Complainant, however, again requested the Opposite Parties to look into his genuine claim, but not finding any favourable response, has preferred the present complaint.

7.                The Opposite Parties defending their action have held their ground that the repudiation was just and legal and as per the terms and conditions of the policy annexed as Annexure R-3. We have minutely gone through the letter found annexed at pg.45 of the complaint, which speaks about Section 8 (Def.7) of the policy, which deals with the criteria of a hospital as per the definition.  After going through the Annexure R-3 at pg.18 of the reply, the clause which is found mentioned under Section 8 (Def.7) is with regard to dependant child and means:-

“a child naturally or legally adopted, who is financially dependent on you and does not have his/her independent sources of income.”

                   It is unfortunate, that the Opposite Parties, while processing the claim of the Complainant have quoted a Section and a definition, which in no manner relates with the case of the Complainant. 

8.                To our mind, once the Opposite Parties have taken a stand vis-à-vis the definition of a treating hospital/ day care treatment, and have mentioned a wrong clause to it, we are of the considered view that the Opposite Parties have not even taken care to go through their own documents before quoting its contents, while communicating the same to the Complainant.    

9.                However, if we go by the facts of the complaint, the son of the Complainant was treated by a qualified ENT Specialist and no fault has been attributed with regard to his qualifications for having treated the Complainant’s son by the Opposite Parties. Furthermore, as per clause 8 (Def.5), the day care treatment is explained as follows:-

“Day care treatment means medical treatment, and/ or surgical procedure which is undertaken under General or Local Anaesthesia in a hospital/ day care centre in less than 24 hrs because of technological advancement, and which could have otherwise required a hospitalization of more than 24 hours, but treatment normally taken on an out-patient basis is not included in the scope of this definition.”

                   Furthermore, the Day Care Procedure, as defined under Sec.1 (e) as follows:-

“The Medical Expenses for a day care procedure mentioned in the list of Day Care Procedures in this Policy where the procedure or surgery is taken by the insured Person as an inpatient for less than 24 hours in a Hospital or standalone day care centre but not the outpatient department of a Hospital or standalone day care centre.”

                   While going through the entire policy document, we have not been able to locate the list of day care procedures, from where it could be ascertained whether the case of the Complainant falls under such category or not.  Under such circumstances, when the Opposite Parties quotes a wrong section while repudiating the claim, and furthermore, tries to hide behind the shortcomings of the policy, which even does not mention the list of day care procedures, cannot be allowed to play truant with the genuine claim of the Complainant.  The Opposite Parties, having repudiated the claim, without going through their own documents properly, have not only been deficient in rendering proper service to the Complainant, but have also caused an ample harassment and agony to him. 

10.              In the light of above observations, the present complaint of the Complainant is allowed, qua opposite parties No.1 & 2. The Opposite Parties No.1 & 2 are directed to:-

[a]     To pay the claim amount of Rs.11,325/- to the Complainant;

[b)     To pay Rs.7,000/-on account of deficiency in service and causing mental and physical harassment to the Complainant; 

[d]    To pay Rs.5,000/- as cost of litigation;

11.              The above said order shall be complied within 45 days of its receipt by the Opposite Parties No.1 & 2; thereafter, they shall be liable for an interest @18% per annum on the amount mentioned in per sub-para [a] & [b] of para 10 above, apart from cost of litigation of Rs.5,000/-, from the date of institution of this complaint, till it is paid.  

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

Announced

08^th May, 2013.                                        

                                          Sd/-

(LAKSHMAN SHARMA)

PRESIDENT

Sd/-

 (MADHU MUTNEJA)

MEMBER

Sd/-

(JASWINDER SINGH SIDHU)

MEMBER