Haryana

Karnal

CC/376/2018

Kartik Gandhi - Complainant(s)

Versus

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

04 Jun 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                         Complaint No.376 of 2018

                                                         Date of instt. 28.12.2018

                                                         Date of decision:04.06.2019

 

Kartik Gandhi son of Shri Yashpal Gandhi residne tof 39 Jernailly Colony, Karnal, phone no.8950122320, Aadhaar no.505814365760.

                                                                                                                                                                               …….Complainant

                                        Versus

 

1. Apollo Munich Health Insurance co. Ltd., shop no.103, 2^nd floor old Mugal, Karnal Haryana-132001.

2. Mr. Ravi Pratap Mourya, Appollo Munich Health Insurance Co. Ltd. Karnal Haryana-132001.

 

                                                                      …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act. 

         

Before     Sh. Jaswant Singh……President.

                 Sh. Vineet Kaushik………Member

 

 Present:   Complainant in person.

                   Shri Rahul Bali Advocate for OP no.1.

                   Opposite party no.2 given up.

 

                   (Jaswant Singh President)

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that the complainant purchased a Health Insurance Policy bearing policy no.111300/11300/AA00761483 from OP no.1 on 15.02.2018. The complainant was diagnosed with Dengue and decline in platelets and had undergone treatment at Shri Sanatan Dharam Mahabir Dal Hospital from 29, September to 3, Oct, 2018 at Karnal, Haryana. After getting well on 4^th October, 2018, complainant opted for the claim of Rs.5000/- from his Reserve Benefit in Health Policy for an expense of Rs.7500/- but it was rejected by OP no.1 on the false and baseless ground. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs. OP no.1 appeared and filed written version raising preliminary objections with regard to maintainability and concealment of true and material facts. On merits, it is pleaded that Mr. Kartik Gandhi (the policy holder/complainant) had provided his consent for issuance of Health Wallet Individual Policy with a basic sum insured of Rs.3,00,000/-. It is further pleaded that OP company received claim of the complainant for reimbursement of Rs.7500/- on 8.10.2018 and complainant submitted claim documents. It is further pleaded that complainant submitted only final bill dated 03.10.2018. As per available bills submitted it was noted that complainant admitted in hospital on 29.09.2018 and was discharged on 3.10.2018. Complainant had not submitted Discharge summary or investigation report. However, OP was not able to find current diagnosis from which complainant was admitted in hospital. Further, in order to get a clarity a query letter dated 16.10.2018 was sent to the complainant for providing the following documents:

. All investigation report/films performed and supporting the final diagnosis.

. Details discharge summary on the hospital letterhead; specifying details like DoA, ToA, DoD, ToD , chief complaints, exact diagnosis, line of Treatment, Advise on Discharge (and any other details that may be required)

When no reply was received from the complainant a reminder was sent vide letter dated 9.11.2018 and then again on 24.11.2018. The complainant has not reverted to queries of the company which was sent to complainant. When no revert was received, the claim of the complainant was rejected for pending documents vide claim rejection letter dated 4.10.2018. The claim of the complainant was repudiated for want of the documents and in case complainant submits the pending documents, the company is ready to review the claim on the basis of the available documents in light of terms and conditions of the policy. There is no deficiency in service on the part of the OP no.1. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             OP no.2 given up vide order dated 29.1.2019

4.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C12 and closed the evidence on 15.04.2019.

5.             On the other hand, OP no.1 tendered into evidence affidavit of Deepti Rustagi Ex.RW1/A and documents Ex.R1 to Ex.R5 and closed the evidence on 22.05.2019.

6.             We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.

7.             The case of the complainant in brief is that, he purchased a Health Insurance Policy on 15.02.2018 from the OP. The complainant was diagnosed with Dengue and had undergone treatment from 29.9.2018 to 3.10.2018 in hospital at Karnal and spent Rs.7500/- for the treatment. Complainant submitted his claim of Rs.5000/- from his reserve benefit in the said policy, which was rejected by the OP without any cogent reason.

8.             On the other hand, the case of the OP is that OP received a claim from the complainant for reimbursement of Rs.7500/- on 8.10.2018. As per bills submitted, it was noted that complainant admitted in hospital on 29.9.2018 and was discharged on 3.10.2018. The complainant had not submitted the discharge summary or investigation report. However, the OP was not able to find current diagnosis for which complainant was admitted in the hospital. When no revert was received, the claim of the complainant was rejected on 04.10.2018. The claim of the complainant was repudiated on want of documents and in case the complainant submit the pending documents, the OP is ready review the claim on the basis of available documents in the light of terms and conditions of the policy.

9.             Admittedly, complainant had taken treatment during the subsistence of the policy and spent Rs.7500/- on his treatment. The counsel for the complainant argued that the documents which were demanded by the OP is only required in OPD and IPD cases and not for reserve benefit cases. The claim of the complainant fall in the category of reserve benefits cases. Thus, plea of the OP is not maintainable. On the other hand, counsel for the OP argued that company is ready to review the claim of the complainant, if he submits the required documents. OP is ready to review the claim of the complainant if the complainant submits the required documents. So, at this stage, we are of the considered view, the act of the OP does not amounts to deficiency in service.

10.            Thus, as a sequel to abovesaid discussion, we dispose off the present complaint with the direction to the complainant to submit the documents required by the OP as per terms and conditions of the policy. We also direct the OP to release the claim of the complainant within 30 days of receipt of documents from the complainant. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:04.06.2019

                                                                       

                                                                  President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal   

                (Vineet Kaushik)

                    Member