Haryana

Kaithal

101/20

Harsh Sharma - Complainant(s)

Versus

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

Sh.Hem Raj Wadhwa

08 Jan 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KAITHAL

 

                                                               Complaint Case No. 101 of 2020.

                                                               Date of institution:    27.02.2020.

                                                               Date of decision:       08.01.2024.

 

Harsh Sharma (aged 9½ years minor) s/o Shri Surender Sharma, through his father Surender Sharma, as next friend/minor, r/o village and Post Office Chhot, Tehsil Kaithal, Kaithal.

                                                                                      …Complainant.

                                                     Versus

 

1. Apollo Munich Health Insurance Co. Ltd., Central Processing, 2^nd & 3^rd Floor, Centre, Plot No.404/405, Udyog Marg, Gurgaon-122016, through its M.D.

1(a)HDFC Ergo Health Insurance Limited, 2^nd and 3ed Floor, Centre, Plot   

       No.404/405, Udyog Marg, Gurgaon, through its M.D.

2. Axis Bank Ltd., Kaithal, through its Branch Manager.

...Opposite Parties.

 

          Complaint under Section 35 of the Consumer Protection Act

 

 

CORAM:   SMT. NEELAM KASHYAP, PRESIDENT.

                   SMT. SUMAN RANA, MEMBER.

                   SHRI SUNIL MOHAN TRIKHA, MEMBER.

                  

Present:       Shri Hem Raj Wadhwa, Advocate for the complainant.   

                   Shri Naresh Sharma, Advocate for Opposite Party No.1.

                   Opposite Party No.1 (a) given up.

                   Shri Sudeep Malik, Advocate for Opposite Party No.2.

                  

ORDER  -  NEELAM KASHYAP, PRESIDENT

        Complainant has filed this complaint under Section 35 of Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’), against the OPs.

2.                It is alleged by the complainant that he alongwith his family members had purchased health insurance policy vide policy No.111300/11229/AX00218699, intermediary No.89005320 through agent OP No.2 valid from 02.08.2019 to 01.08.2020 from OP No.1, who deducted Rs.12460/- from his said account bearing No.916010033599068 of his father with OP No.2. Complainant Harsh suffered from disease Mema Tonsillitis and admitted as indoor patient in Jeewan Jyoti Hospital, Kaithal from 26.12.2019 to 29.12.2019 and spent Rs.7515/- for his treatment there. As per policy, he submitted medical bills with OP No.1, who illegally and unlawfully repudiated his claim on 16.01.2020, with the allegations that the claim is not payable within 24 months waiting period. The above act of OPs of repudiation of his claim, amounts to gross deficiency in service, on their part, due to which, he suffered physical and mental agony as well as financial loss, constraining him, to file the present complaint, against the OPs, before this Commission.

3.             Upon notice of complaint, OPs No.1 & 2 appeared before this Commission and filed their respective written statements, whereas, OP No.1(a) has been given up.

4.                OP No.1, in its written statement specifically stated that if any customer is purchasing any health policy from insurance company, then buyer/purchaser needs to be declare his previous medical and lifestyle information declaration which is given in Para No.5 (Medical questionnaire) of proposal form of health policy and same has to be declared by the buyer/purchaser at the time of taking the policy. It is denied that the complainant has submitted his medical bills with OP No.1, who illegally repudiated the claim, but the same is rejected on policy reasons and mandatory declarations, which needs to be submitted by buyer/purchaser and the same is also binding upon the present complainant and as alleged by the complainant that he has suffered to disease Mema tonsillitis. As per health policy, the diagnosis of complainant is/was of tonsillitis and the said treatment comes under the waiting period of 2 years, whereas, the policy of complainant is/was running on his first year. It is denied that no conditions have been read over to the complainant at the time of purchasing of policy and prayed for dismissal the present complaint.  

5.                OP No.2, in its written statement stated that the present complaint has not been filed by authorized and competent person. The alleged policy was purchased by Shri Surender Kumar, who is account holder of OP bank and the policy in question was also issued in  his name but the present complaint has been filed by Harsh Sharma, who cannot be termed as customer, thus the complaint in hand deserves dismissal.     

6.                To prove the case, complainant tendered into evidence affidavit Ex.CW1/A alongwith documents Annexure-C1 & Annexure-C14.

7.                On the other hand, OP No.2, in its evidence tendered affidavit Ex.RW1/A. OP No.1 failed to lead any evidence in its defence, as such, evidence of OP No.1 has been closed by the order of this Commission on 14.11.2022.

8.                We have heard the learned counsel for the parties and perused the record carefully.

9.                Learned counsel for the complainant has argued that the complainant alongwith his family members had purchased health insurance policy through agent OP No.2 valid from 02.08.2019 to 01.08.2020 from OP No.1. He further argued that complainant suffered from disease Mema Tonsillitis and admitted as indoor patient in Jeewan Jyoti Hospital, Kaithal from 26.12.2019 to 29.12.2019 and spent Rs.7515/- for his treatment there. He further argued that as per policy, the complainant submitted medical bills with OP No.1, who illegally and unlawfully repudiated his claim on 16.01.2020, with the allegations that the claim is not payable within 24 months waiting period. He further argued that OP No.1 never supplied any copy of terms and conditions of the policy in question to the complainant with the policy cover note and the above act of OPs of repudiation of claim of complainant, amounts to gross deficiency in service, on their part. In order to support his contentions, he placed reliance upon case law titled “National Insurance Company Ltd. Vs. Rajan Narain, 2008 (1) CPJ, 501 (NC)”.

10.              On the other hand, learned counsel for OP No.1 has argued that the complainant suffered from disease Mema tonsillitis and as per health policy, the diagnosis of complainant is/was of tonsillitis and the said treatment comes under the waiting period of 2 years, whereas, the policy of complainant is/was running on his first year. Hence, claim of complainant has been rightly repudiated as per terms and conditions of the policy in question.

11.              Learned counsel for OP No.2 has argued that that the present complaint has not been filed by authorized and competent person as the alleged policy was purchased by Shri Surender Kumar, who is account holder of OP bank and the policy in question was also issued in his name but the present complaint has been filed by Harsh Sharma, who cannot be termed as customer, thus the complaint in hand deserves dismissal.

12.              Admittedly, the complainant alongwith his family members had purchased health insurance policy, from OP No.1, through OP No.2, vide policy No.111300/11229/AX00218699, valid from 02.08.2019 to 01.08.2020, with Basic Sum Insured of Rs.3 lacs, vide policy document Annexure C-1, and in this regard, OP No.2 deducted amount of Rs.12460.80 on 02.08.2019, from bank account of Surender Kumar (father of complainant). From medical documents Annexure C-4 to Annexure C-13, produced by the complainant on the case file, we found that the complainant suffered from disease “Mema Tonsillitis” and admitted as indoor patient in Jiwan Jyoti Hospital, Kaithal from 26.12.2019 to 29.12.2019 and spent Rs.7515/- for his treatment there.

13.              The grievance of the complainant is that after taking the treatment from Jiwan Jyoti Hospital, Kaithal, he submitted his claim along with requisite medical bills/documents, with OP No.1, who illegally and unlawfully repudiated his claim on 16.01.2020 Annexure C14, with the allegations that the claim is not payable within 24 months waiting period.

14.               Contrary to it, learned counsel for OP No.2 has raised objection that the policy was purchased by Shri Surender Kumar, who is account holder of OP bank and the policy in question was also issued in his name, but the present complaint has been filed by Harsh Sharma, who cannot be termed as customer. But this objection of OP No.2 has no force, because, no doubt the policy in question Annexure C-1 was purchased by one Surender (father of complainant), but this policy was a family health policy and the complainant Harsh Sharma was a member of that policy, being son of policy holder Surender. Moreover, the claim in question belongs to complainant not to Surender (father of complainant), for which, complainant is liable to file the complaint before this Commission to redress his grievance.  

 15.             From the perusal of said repudiation letter Annexure C-14, we found that OP No.1 had repudiated the claim of complainant, on the specific ground that the policy in question has started on 02.08.2019, but the illness for which complainant is demanding the claim, has a specific 2 years of waiting period, hence, the claim is not payable as per policy terms and conditions Section V(A). In this regard, learned counsel for the complainant has contended that OP No.1 has not supplied the terms & conditions of the policy in question to the policy holder, with the cover note. This contention of the complainant has force, because OP No.1 has not produced any documentary proof to establish that the terms & conditions of the policy in question were duly supplied to the complainant alongwith the policy cover note. Moreover, OP No.1 has also not produced any signed copy of the terms & conditions, by the complainant, as a token of its receipt, vide which, it can be gathered that OP No.1 had acknowledged the complainant about terms and conditions of the policy in question, on the ground of which, OP No.1 has repudiated the claim of the complainant. In this regard, our view is fully supported, by the case law, produced by the complainant, titled as National Insurance Company Ltd. Vs. Rajan Narain (supra), wherein, the Hon’ble National Commission, New Delhi has held that Insured felt chest pain within 3 days of taking policy- Underwent heart surgery three weeks later- Repudiation of claim- On ground of suppression of pre-existing disease alleged- Deficiency of service alleged- Complaint allowed-Compensation awarded – Dismissal of appeal- Challenged by revision-Held, complainant was neither aware of exclusion clause nor was supplied with terms and conditions of policy at time of issuing cover note- Since, complainant having heart disease prior to taking of policy not proved- Thus, complaint rightly allowed- Order upheld- Interference declined- Revision dismissed.

16.              Keeping in view the ratio of the case law, laid down by the superior For a, in the aforesaid case as well as facts & circumstances of the present case, we are of the considered opinion that OP No.1 was not justified to repudiate the claim of the complainant and is liable to pay the amount, which was spent, by the complainant, on his treatment along with compensation and litigation expenses.

17.              In the complaint, complainant alleged that he had spent Rs.7515/- on his treatment in Jiwan Jyoti Hospital, Kaithal and to corroborate the same, he produced medical bills in this regard as Annexure C-4 to Annexure C-13 respectively. Hence, OP No.1 is liable to pay Rs.7515/- along with compensation amount and litigation amount of Rs.5000/- to the complainant. Since no kind of specific allegation has been leveled, by the complainant, against OP No.2, nor the same has been proved, therefore, complaint qua OP No.2 is liable to be dismissed.

18.              In view of our above discussion, we accept the present complaint against OP No.1 and dismiss the same against OP No.2. We direct OP No.1 to pay Rs.7515/- along with lump-sum amount of Rs.5000/- as compensation amount + litigation expenses, to the complainant, within a period of 45 days, from the date of preparation of certified copy of this order, failing which, the total award amount shall carry interest @6% simple per annum, from the date of this order, till its actual realization.

19.              In default of compliance of this order, proceedings shall be initiated under Section 72 of Consumer Protection Act, 2019, as non-compliance of Court order shall be punishable with imprisonment for a term which shall not be less than one month, but which may extend to three years, or with fine, which shall not be less than twenty five thousand rupees, but which may extend to one lakh rupees, or with both. A copy of this order be sent to the parties free of cost. File be consigned to the records, after due compliance.     

Announced in open Commission:

Dt.:08.01.2024.

                                                                                      (Neelam Kashyap)

                                                                                      President.

 

(Sunil Mohan Trikha).             (Suman Rana).              

Member.                                  Member.

 

 

 

 

 

 

 

 

 

 

Typed by: Sham Kalra, Stenographer.