Chandigarh

DF-I

CC/407/2014

Muneshwar Singh Khaira - Complainant(s)

Versus

Apollo Munich Health Insurance Company Limited. - Opp.Party(s)

Vikram Tandon

18 Feb 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

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Consumer Complaint No.	:	CC/407/2014
Date of Institution	:	18/06/2014
Date of Decision	:	18/02/2015

 

 

Muneshwar Singh Khaira son of Sh. Hardial Singh Khaira, Quite Office No.4, First Floor, Sector 35-A, Chandigarh.

…..Complainant

V E R S U S

Apollo Munich Health Insurance Company Limited, Branch Office, SCO No.51, Sector 34-A, Chandigarh through its Branch Manager.

……Opposite Party

 

 

QUORUM:	P.L.AHUJA	PRESIDENT
	MRS.SURJEET KAUR	MEMBER

                                               

                                               

                       

For complainant	Sh. Vikram Tandon, Advocate
For OP	Sh. Sandeep Suri, Advocate

                       

                 

PER P.L.AHUJA, PRESIDENT

1.         Sh. Muneshwar Singh Khaira, complainant has filed this consumer complaint under Section 12 of the Consumer Protection Act, 1986, against Apollo Munich Health Insurance Company Limited, Opposite Party (hereinafter called the OP), alleging that he alongwith his family members took Health Insurance Policy namely Optima Restore Insurance Coverage Policy effective from 7.5.2013 to 6.5.2014 (Annexure C-1) from the OP through the agency namely Berkeley Retail, Chandigarh.  According to the complainant, he has been taking medical insurance from different insurance companies for the last 6-7 years continuously and he never lodged any medical claim. 

                On 10.5.2013, the complainant was suffering from loose stools and low grade fever and due to this reason on 11.5.2013 he went to Ivy Hospital, Super Specialty Healthcare, Sector 71, Mohali. After examination, the doctors diagnosed the complainant with acute gastroenteritis after which he was admitted for treatment and was discharged on 13.5.2013. It has been averred that on 11.5.2013 the hospital authorities had sent intimation about complainant’s hospitalization but, at the time of discharge on 13.5.2013, he came to know that the OP had refused to accept the cashless policy through hospital. Ultimately the complainant had to pay his medical bills amounting to Rs.33,799/-. Thereafter, the complainant lodged claim with the OP alongwith all the necessary documents on 17.6.2013 (Annexure C-4) but the OP vide letter dated 24.6.2013 sought certain documents from him.   On 19.7.2013, when the complainant asked for the said documents from the hospital authorities, he was told vide email dated 19.7.2013 that the representative of the OP could come and check the same in the hospital.  On 26.7.2013 documents regarding diabetic flow sheet of the complainant and certificate dated 18.7.2013 of the doctor were submitted to the OP but vide email dated 12.8.2013 (Annexure C-7), the OP closed the case due to non-submission of documents. On 19.1.2014, the OP again sent an email Annexure C-8 seeking certain documents which were supplied by the complainant through letter dated 13.3.2014 (Annexure C-9).  On 28.3.2014, the OP again sent an email (Annexure C-10) and sought certain more documents.  The complainant wrote letter dated 3.4.2014 (Annexure C-11) to the OP intimating that as he was not a patient of hypertension or diabetes, therefore, there was no previous record or papers regarding those diseases. However, vide letter dated 26.4.2014 Annexure C-14 (Annexure C-13?) the complainant’s claim was closed due to non-submission of certificate regarding duration and past history of DM (Diabetes), HTN (Hypertension) as per indoor case papers and all past treatment records with 1^st consultation.  Alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on the part of the OP, the complainant has filed the instant complaint. 

2.         In its reply, OP has admitted that the policy in question was issued to the complainant. It has been averred that the medical records pertaining to the complainant categorically showed that he was unknown (known?) case of DM (diabetes) and hypertension which had been clearly mentioned in the indoor case of papers pertaining to the patient and had also been mentioned in the certificate issued by the concerned hospital. It has been averred that had the OP knew about the pre-existing diseases, it would have materially influenced it in making the contract of insurance and in estimating the degree and character of risk, fixing the rate of premium and even declining the risk. It has been pleaded that as per the documents, the complainant was not discharged on 13.5.2013 but on 12.5.2013.  It has been denied that the OP had refused the cashless facility and, in fact, the same was cancelled by the hospital.  It has been pleaded that the complainant lodged claim but complete documentation was not provided even after several communications due to which claim was closed.  Pleading that there is no deficiency in service or unfair trade practice on its part, OP has prayed for dismissal of the complaint.
3.         In his replication, the complainant has controverted the stand of the OP and reiterated his own.  It has been pleaded that the complainant was not suffering from diabetes or hypertension but the same had been detected by him recently. The complainant has contended that he has not filed the present complaint on the basis of diabetes or hypertension but for diarrhea only. 
4.         The parties led evidence in support of their contentions.
5.         We have scanned the entire evidence, written arguments submitted by both sides and heard the arguments addressed by the learned Counsel for the complainant. 
6.         It is the admitted case of the OP that the complainant alongwith his family members had taken health insurance policy namely Optima Restore Insurance Coverage Policy, copy of which is Annexure C-1, through Berkeley Retail agent for the period from 7.5.2013 to 6.5.2014. It is also admitted that the complainant has been taking medical insurance from different insurance companies for the last 6-7 years. As per copy of discharge summary Annexure C-2, coupled with the averments of the complainant, the complainant was suffering from loose stools (motions) and low grade fever and he was admitted in Ivy Hospital Super-Speciality Healthcare, Sector 71, Mohali and diagnosed with acute gastroenteritis and after giving treatment was discharged on 13.5.2013. Though as per averments of the OP, the complainant was discharged on 12.5.2013 and there is a document at Annexure R-6 from Ivy Hospital to this effect, yet the copies of the discharge summary from the Ivy Hospital Annexure R-9 and R-10 produced by the OP also show the date of discharge as 13.5.2013. The complainant submitted a claim form, copy of which is Annexure C-4 with the OP and the copy of email message dated 12.8.2013 (Annexure C-7) shows that the case was closed by the OP due to non-submission of documents. It was mentioned that attested copies of indoor case papers of hospitalization including admission notes and daily progress notes, treating doctor’s certificate regarding need of tablet Gluconorm given to the patient during hospitalization were required. Vide letter dated 13.3.2014 (Annexure C-9), the complainant informed the OP that record of the hospitalization was available in the hospital and it could be verified by their representative. He also enclosed copies of available hospital record. He asserted that he was not asking the company for the reimbursement of any expenses relating to diabetes. He also enclosed one certificate dated 12.2.2014 given by the treating doctor certifying that his admission in the hospital was primarily because of the problem of diarrhea and after being discharged from the hospital, Dr. Vipul Mittal did not advise him any medicine for sugar. The complainant also sent letters dated 3.4.2014 and 16.4.2014 (Annexure C-11 and C-12) but vide letter dated 26.4.2014 (Annexure C-13) the claim of the complainant was closed on the ground of deficiency in documents i.e. treating doctor certificate regarding duration and past history of diabetes and hypertension as per indoor case papers and all past treatment records with first consultation.
7.         As per case of the OP according to the medical record, the complainant was unknown (known?) case of DM (diabetes) and hypertension which was clearly mentioned in his indoor case of papers pertaining to the patient. It has been contended on behalf of the OP that the complainant has himself stated that he is suffering from these diseases but he has only recently developed the same. It has been pleaded by the OP that the complainant was issued letters dated 24^th June 2013, 10^th July 2013, 23^rd July 2013, 26^th March 2014, email 28^th March, 2014, 11^th April 2014, 12^th April 2014, 24^th April 2014 and 26^th April 2014, but he failed to provide the requisite documents.
8.         It has been argued by the OP in the written arguments that the medical record shows that the complainant was suffering from pre-existing diseases of diabetes and hypertension but in spite of repeated requests, the medical record of the pre-existing diseases was not provided. The OP has drawn our attention to the copy of the proposal form Annexure R-1 and has contended that the complainant did not provide any information that he was suffering from diabetes or hypertension.  It has been urged that in case of wrong disclosure, the policy is liable to be declared as void. It has also been submitted that the documents were asked in order to take appropriate decision and had diabetes and hypertension been disclosed at the proposal stage, the said policy would never had been issued.   The complainant has drawn our attention to Maya Devi Vs. Life Insurance Corporation of India, Revision Petition No.2091 of 2007 decided on 31.5.2011 by the Hon’ble National Commission and has contended that the claim of the complainant was declined due to non-disclosure of material facts and the repudiation by the OP is in consonance with the decision in the above ruling.  It has also been contended that Gluconorm is a drug which lowers blood glucose and is used in the treatment of Type 2 diabetes which shows that the complainant was under treatment for diabetes.
9.         We have carefully considered the above arguments. The copy of the proposal form dated 1.5.2012 Annexure R-1 produced by the OP shows that the complainant in his declaration regarding medical and life style information had mentioned that he was not suffering from hypertension and diabetes apart from other diseases.  However, the present complaint does not relate to the diseases of hypertension and diabetes but relates to the expenses on the treatment of acute gastroenteritis during the period from 11.5.2013 to 13.5.2013.  The copy of letter dated 26.4.2014 (Annexure C-13) shows that the OP had received the attested copy of indoor case paper of hospitalization including admission and daily progress notes; glucose glucometer test dated 11.5.2013 and 12.5.2013 and treating doctor certificate regarding tablet Gluconorm given to the patient during hospitalization but the copy of the cancelled cheque with payee name and the treating doctor certificate regarding duration and past history of diabetes and hypertension and all past treatment records were not provided. The copy of certificate dated 12.2.2014 (Annexure R-14) of Dr. Vipul Mittal, treating doctor of Ivy Hospital, shows that he certified that the patient presented with Diarrhea and had +++ (3x) sugars for which tablet Gluconorm was given and as per patient he was a recently diagnosed case of HTN and Type 2 DM and was on Gluconorm SR Amtas – M.  He also certified that patient was admitted in hospital for diarrhea only and not for diabetes & HTN and his previous treatment was continued as such old records were with patient only.  The copy of letter dated 3.4.2014 at page 76 of the OP’s documents shows that the problem of hypertension and sugar came to the notice of the complainant when he continued remaining worried because of illness. Before being admitted in the hospital, he had consulted a local physician who indicated that possibly he was having sugar due to hypertension but as no treatment was taken by him he had no record/papers for it.  Similarly, in the letter dated 16.4.2014 (at page 79 of OP’s documents), the complainant reiterated that he had not taken any treatment for DM and HTN so it was not possible for him to submit the required certificate from any doctor. He reiterated that these symptoms (for diabetes and hypertension) came to his knowledge only recently.  OP has failed to produce any such document which could show that the complainant was aware that he was suffering from diabetes and hypertension on 1.5.2012 (the date on which he signed the proposal form Annexure R-1). Thus, the contention of the complainant that he came to know of the diseases of diabetes and hypertension a few days earlier to his admission in Ivy Hospital on 11.5.2013 for treatment of acute gastroenteritis inspires confidence. It is quite probable that the complainant developed the diseases of diabetes and hypertension after 1.5.2012.  Hence, it cannot be stated that the complainant concealed any material facts at the time of filling up of the proposal form on 1.5.2012.  To cap it all, the claim of the complainant has not been repudiated by the OP on the ground that the complainant had concealed the pre-existing diseases of diabetes and hypertension at the time of filling up of the proposal form for insurance (Annexure R-1).  On the other hand, the claim of the complainant was closed because of non-submission of some documents only.  The OP in its written reply has itself mentioned that the complainant was unknown case of DM (diabetes) and hypertension.  The fact that the claim of the complainant has been repudiated for all intent and purposes is clear from the assertion in the written arguments of the OP wherein it has been mentioned that the claim of the complainant was declined due to non-disclosure of material facts and said repudiation by OP company is in consonance with the decision in Maya Devi Vs. Life Insurance Corporation of India (supra). The copy of judgment in the said case makes it clear that in that case the deceased husband of the complainant was a known case of diabetes for the last 10 years and he had suppressed the material facts.  Thus, the said decision was passed by the Hon’ble National Commission on a different set of circumstances. In the instant case, the material on record does not prove that the complainant suppressed material facts of any pre-existing disease at the time of filling up of the proposal form.  Further, the evidence on record makes it clear that the complainant was treated for acute gastroenteritis and he was admitted for that purpose only in Ivy Hospital, Mohali for the period from 11.5.2013 to 13.5.2013. Consequently, the act of non-reimbursement of the expenses actually incurred by the complainant for the period from 11.5.2013 to 13.5.2013 in Ivy Hospital amounts to deficiency in service on the part of the OP.
10.         For the reasons recorded above, we find merit in the complaint and the same is allowed partly.  OP is directed as under :-
    1. To make payment of an amount of Rs.33,799/- spent by the complainant on his treatment with interest @ 9% per annum from the date of filing of the claim till realization.
    2. To pay Rs.15,000/- to the complainant towards compensation for harassment and deficiency in service.
    3. To pay Rs.7,500/- to the complainant towards litigation expenses.
11.         This order shall be complied with by OP within one month from the date of receipt of its certified copy; thereafter OP shall pay the amounts mentioned at Sr.No.(i) and (ii) above with interest @ 12% per annum from the date of filing of the present complaint till realization by the complainant, besides payment of litigation costs.
12.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-
18/02/2015	[Surjeet Kaur]	[P. L. Ahuja]
hg	Member	President

                                                               

 

 

 

DISTRICT FORUM – I

CONSUMER COMPLAINT NO.  407 of 2014

PRESENT: None.

O R D E R                 17th February, 2015 was a holiday on account of Maha Shivratri.                 Vide our detailed order of even date, recorded separately, the complaint has been partly allowed.

 

 

 

18/02/2015	[Surjeet Kaur]	[P. L. Ahuja]
	Member	President