Punjab

Faridkot

CC/19/202

Pardeep Kumar - Complainant(s)

Versus

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

Sukhwant Singh Sandhu

23 Jul 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :      202 of 2019

Date of Institution:   14.08.2019

           Date of Decision :    23.07.2024

Pardeep Kumar alias Pardeep Garg aged about 44 years son of Hem Raj Garg, r/o House No. 90, Ward No.10, Near Ram Leela Ground, Jaitu, Tehsil Jaitu, District Faridkot.

                                                                           .........Complainant

Versus

1. Apollo Munich Health Insurance Company Ltd, Reg. Off: Apollo Hospital Complex, Jubilee Hills, Hyderabad-500033, Telangana through its Managing Director /Director/ Manager/ Authorized Person.
2. HDFC Bank, Hospital Road, Jaitu, Tehsil Jaitu, District Faridkot through its Branch Manager/ Authorized   Person /Incharge / Responsible Person.

                                                                          .............OPs

Complaint under Section 12 of the

Consumer Protection Act, 1986.

(Now, under Section 35 of the Consumer Protection Act, 2019)

 

Quorum: Sh. Rakesh Kumar Singla, President,

               Smt. Param Pal Kaur, Member.

 

Present:  Sh Neeraj Maheshwary, Ld Counsel for Complainant,

               Sh Ashu Mittal, Ld Counsel for OP-1,

                OP-2 Exparte.

ORDER

(Rakesh Kumar Singla, President)

 

cc no.-202 of 2019

                                             Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against  OPs seeking directions to OPs to make payment of insurance claim of Rs.40,452/-with interest and for further directing OPs to pay Rs.50,000/- as compensation for deficiency in service and harassment alongwith litigation expenses of Rs.10,000/-.

2                                   Briefly stated, the case of the complainant is that on assurance of Ops, complainant purchased the mediclaim insurance policy bearing no.160100/ 12580 /2019/ A014634 / PE 01344094 in January, 2019 from OP-1 valid from 24.01.2019 to 23.01.2020 for a sum of Rs.5,00,000/- and said policy covered the risk of accident and health insurance of complainant. It is submitted that in May 2019, complainant had some problem and after diagnosis from the Daya Nand Medical College and Hospital, Ludhiana, it was found that he was suffering from DM-2, HTN, Fatty Liver with Low Bachache with Left Leg pain with cystitis and for the purpose of treatment, he was admitted in hospital on 04.05.2019 and was discharged therefrom on 11.05.2019 and since then, complainant has been regularly taking treatment from said hospital. It is further submitted that prior to this, he never had this problem. Complainant spent Rs.40,452/-on his treatment and thereafter, he duly informed Ops through telephone as well as through written letters and by e-mail regarding treatment undertaken by him and also submitted all the requisite documents to Ops with request to pass the insurance claim, but Ops rejected the claim of complainant on the ground that his claim

cc no.-202 of 2019

comes under exclusion list meaning thereby treatment of Cholelithiasis is excluded from the Policy if admitted in one year of date of inception of policy. It is contended that complainant has never taken the treatment of cholelithiasis, rather he has claimed for the treatment of Peptic Ulcer disease, DM, HTN and Left Plexopathy which do not come under exclusion clause of the Insurance Policy purchased by the complainant. At the time of issuance of Policy in question, Ops assured him that all diseases were covered under the policy and gave assurance regarding passing the claim within short interval of time and at that time no such hidden clause was disclosed by OPs to him. Only single page document was issued to him and such terms and conditions of exclusion clause were neither explained nor given to him at the time of releasing the policy in question. Despite repeated requests, OPs have not made a single penny on account of insurance claim of complainant, which amounts to deficiency in service and has caused harassment and mental tension to him.Complainant has prayed for directing the OPs to pay compensation alongwith litigation expenses besides the main relief. Hence, the complaint.

3                                    The counsel for complainant was heard with regard to admission of the complaint and vide order dated 21.08.2019, complaint was admitted and notice was ordered to be issued to the OPs.

4                                     On receipt of the notice, the OP-1 filed written statement taking preliminary objections that complaint filed by

cc no.-202 of 2019

complainant is vague, vexatious and false and it has been filed by complainant with malafide and dishonest intention. He has concealed the material facts and has twisted the same. No cause of action arises against answering OP and there is no deficiency in service on their part. Moreover, this Forum has no jurisdiction to hear and try the present complaint and there is no deficiency in service on their part. It is averred that on 05.05.2019, answering OP received a cashless request for complainant who got admitted in Dayanand Medical College & Hospital, Ludhiana on 04.04.2019 with provisional diagnosis as Cholithiasis and claimed Rs.37,700/-, which was rejected vide letter dated 05.05.2019 as treatment for Cholelithiasis is excluded from the policy if admitted within one year of issuance of policy. After that hospital sent TDC stating that complainant was not treated for Cholelitiasis, the treatment was for weakness and Anaemia. Hospital sent a revised preauthorization form by changing provisional diagnosis as Anaemia with weakness for I/V antibiotics. The line of treatment was not justified as diagnosis mode and thus, claim was rejected on 06.05.2019 on the ground that indication for hospitalization cannot be established. After that complainant submitted a claim for reimbursement on 05.07.2019 and as per discharge summary, complainant was treated for Peptic ulcer disease, which falls under waiting period of one year. Hence, claim of complainant was rejected as per Section 2A (ii) of the terms and conditions of the present Insurance Policy. There is no deficiency in service on the part of OPs in rendering services to

cc no.-202 of 2019

 complainant. it is further averred that policy is a legal contract between complainant and answering OP and all are bound by the terms and conditions of the policy and  Insurance Company has no liability to pay the amount as sought by the complainant. However, on merits, ld counsel for OP-1 has denied all the allegations of complainant being wrong and incorrect and reiterated the same pleadings as taken in preliminary pleadings. All the other allegations and allegation with regard to relief sought too were refuted with a prayer that complaint deserves to be dismissed with costs.

5                                                     Registered Cover containing copy of complaint alongwith summons was sent to OP-2 and it did not receive back undelivered. Acknowledgment might have been lost in transit. It is assumed that OP-2 has been duly served but nobody appeared in the Forum on behalf of OP-2 in the Forum on date fixed either in person or through counsel to contest the allegations levelled by complainant and therefore, OP-2 was proceeded against exparte vide order dated 13.11.2019.

6                                              Parties were given proper opportunities to prove their respective case. Counsel for complainant tendered in evidence her affidavit Ex.C-1, proposal form Ex C-2, Insurance Policy Ex C-3, rejection letters Ex C-4 to C-8, documents in respect of treatment undertaken at Dayanand Medical College and Hospital,

 

 

cc no.-202 of 2019

Ludhiana Ex C-9 to C-58, Adhaar Card of complainant Ex C-50 and documents Ex C-59 to C-61 and then, closed their evidence.

7                                              In order to rebut the evidence of the complainant, ld counsel for OP-1 tendered in evidence affidavit of Abhishek Kumar Ex OP-1/A and document Ex OP-1/1 to 6 and then, closed the same on behalf of OPs.

8                                              We have heard the ld counsel for complainant as well as OPs and have carefully gone through evidence and documents placed on record by respective parties.

9                                       From the careful perusal of evidence and documents placed on record and pleading made by parties in above discussion, it is observed that there is no dispute regarding insurance of complainant with OPs. Ops have themselves admitted that complainant was insured with them for cashless treatment under the policy in question. It is also admitted that he remained hospitalized for the  period from 04.05.2019 to 11.05.2019. From the documents available on record, it is evident that during the subsistence of said policy, he undertook treatment for DM-2, HTN, Fatty Liver with Low Bachache with Left Leg pain with cystitis from DMC, Ludhiana and spent about Rs.40,452/- on his treatment as per bill Ex C-14.

10                                   Grievance of the complainant is that despite completion of all formalities, submission of requisite documents as demanded by OPs and even after several requests by OPs, they

cc no.-202 of 2019

repudiated the claim of complainant vide letter Ex C-6, on the ground that treatment of Cholelithiasis undertaken by complainant is excluded from the policy as complainant was admitted in hospital within one year of policy inception date. On the other hand, plea taken by OPs is that treatment of cholelithiasis undertaken by complainant comes under exclusion clause as it was undertaken by complainant within one year of inception of policy in question.

11                                   To prove his pleadings, ld counsel for complainant has stressed mainly on document Ex C-13 which is copy of Discharge Summary that vanishes all doubts regarding treatment undertaken by complainant.  Its indicates that complainant was diagnosed at Daya Nand Medical College and Hospital, Ludhiana, having DM-2, HTN, Fatty Liver with Low Backache with Left Leg pain with cystitis and for the purpose of treatment, he was admitted in hospital on 04.05.2019 and was discharged therefrom on 11.05.2019. there is no doubt that he remained admitted there from 4.05.2017 to 11.05.2017 and spent about Rs.40,452/- vide bill dated 11.05.2019 on his treatment and thereafter, he lodged claim with OPs.  But repudiation letter Ex C-6, reveals that claim of complainant was rejected for exclusion clause as treatment of  Cholelithiasis undertaken by complainant was within one year of inception of policy and is exclude for reimbursement. It is noticed that  Ops wrongly repudiated the claim for the  exclusion clause because complainant did not undertake any treatment for cholelithiasis, rather he underwent treatment for the

 

cc no.-202 of 2019

ailments for which he was diagnosed i.e DM-2, HTN, Fatty Liver with Low Bachache with Left Leg pain.

12                                     Ld counsel for complainant has further brought our attention towards document Ex OP-1/1 which is produced by OPs themselves. This document is copy of certificate issued by Dayanand Medical College and Hospital, Ludhiana dated 05.05.2019 wherein it is clearly mentioned that Patient Pardeep Kuamr was admitted for generalized weakness and anaemia and not for the treatment of cholelithiasis. This document also clearly reveals the fact that complainant was undertaking treatment for anaemia, leg pain and weakness. Thus, plea taken by OPs that treatment taken by complainant comes under exclusion clause and is not payable, has no legs to stand upon and amounts to deficiency in service on the part of OPs.

13                      Careful perusal of Claim Form Ex OP-1/4 adduced on record by OP-1 also proves the pleadings of complainant that he took treatment for DM-2, HTN, Fatty Liver with Low Bachache with Left Leg pain with cystitis and not for Cholelithiasis.

14                          It is observed that OPs cannot deny the amount in dispute regarding claim of complainant on the ground of non exclusion clause. It is generally seen that Insurance Companies are only interested in earning the premiums and find ways and means to decline the claims. He  further placed reliance on citation 2008(3)RCR (Civil) Page 111

cc no.-202 of 2019

titled as New India Assurance Company Ltd Vs Smt Usha Yadav & Others, wherein our Hon’ble Punjab & Haryana High Court held that it seems that Insurance Companies are only interested in earning premiums and find ways and means to decline the claims.

15                                    In the light of above discussion, documents placed on record and case law produced by the complainant, we are of considered opinion that Insurance Company has wrongly and illegally not processed the claim of complainant, which amounts to deficiency in service and unfair trade practice. Moreover, Consumer Protection Act is for the welfare and benefit of complainant. Therefore, present complaint is hereby partly allowed against OP-1/ Insurance Company. OP-1 is directed to pay the claim amount of Rs.40,452/- to complainant, that he has incurred on his treatment vide bill dated 11.05.2019 Ex C-14 alongwith interest at the rate of 6% per anum from the date of institution of present complaint till final realization. OP-1 is further directed to pay Rs.5,000/- to complainant as compensation for harassment and mental agony suffered by him and Rs.5000/- for litigation expenses.

16                                      Compliance of this order be made within 45 days from the date of receipt of the copy of the order, failing which complainant shall be entitled to proceed as per Consumer Protection Act 2019.

 17                                   Complaint against OP-2/Bank stands hereby dismissed as it has no role in making payment of insurance claim.

cc no.-202 of 2019

18                                   Complaint could not be decided within statutory period due to incomplete quoram and heavy pendency of work.

19                                     Copy of the order be supplied to parties free of cost as per law.

20                            File be consigned to record room.

Announced in Commission

Dated :  23.07.2024

 

     (Param Pal Kaur)      (Rakesh Kumar Singla)

                                    Member                     President