Chandigarh

DF-II

CC/52/2016

Mayank Khosla - Complainant(s)

Versus

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

Vikram Tandon Adv.

05 Oct 2016

ORDER

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

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Consumer Complaint  No	:	52 of 2016
Date  of  Institution	:	21.01.2016
Date   of   Decision	:	05.10.2016

 

 

 

 

Mayank Khosla son of Sh.Ramesh Chander, resident of H.No.559, Sector 10, Chandigarh.

             …..Complainant

Versus

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

….. Opposite Party  

 

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         MRS.PRITI MALHOTRA             MEMBER

 

 

For complainant(s)      : Sh.Vikram Tandon, Advocate

 

For Opposite Party(s)   : Sh.Sandeep Suri, Advocate.

 

 

PER PRITI MALHOTRA, MEMBER

 

 

          As per the case, the complainant took Health Insurance Policy namely Easy Health Floater Standard; Two Years Policy through namely Berkeley Retail, Chandigarh, effective from 15.6.2014 to 14.6.2016 and paid an amount of Rs.17,433.97P as premium (Ann.C-1). It is averred that the complainant had taken health insurance policy since 2010 and no medi-claim has ever been taken by him.  Unfortunately, on 01.04.2015, the complainant met with an accident and received serious injuries. A DDR No.25, dated 15.4.2015 at P.S. Lalru, District SAS Nagar, Mohali was registered. On 2.4.2015, the complainant was admitted in Fortis Hospital, Mohali and treated for the injuries on his right thigh whereby he was operated upon and Distal Femur Plating was done on right leg, 10 hole distal femur locking plate placed across fracture site and 5 distal and 5 proximal locked done on 3.4.2015. Thereafter, the complainant was discharged from the Hospital on 6.4.2015 and bill amounting to Rs.2,00,928/- was raised by the Hospital out of which the Opposite Party paid an amount of Rs.1,93,673/- and the balance amount of Rs.7256/- was paid by the complainant.  Unluckily, the complainant on 25.4.2015 due to fall on the floor, sustained injury on the right leg and due to which the screws backed-out of the wound planted by the doctor on 3.4.2015 and old incision plate and fracture site were exposed.  Therefore, the complainant was admitted in Fortis Hospital, Mohali on 26.4.2015 and was again given the treatment of “Fracture reduction done, old plate used and re-adjusted, five distal and five proximal screws placed, bone grafting lefts ASIS taken and grafted over fracture site, wound closure done over negative suction drain, ASD done, Slab applied.”, for which the hospital raised bill of Rs.2,05,293/-, which was paid by the complainant as the Opposite Party refused the request of the complainant for cashless treatment. It is pleaded that the Opposite Party denied the cashless treatment on the ground of complainant’s having history of epilepsy more than 8 years back (Ann.C-4 & C-5). However, the complainant explained the whole position to the Opposite Party vide letter dated 24.5.2015 (Ann.C-14) to the effect that he was suffering from epilepsy and that was cured and for the last 8/10 years, he is not taking any medicine for the same and doctor also issued a certificate to that effect (Ann.C-8). It is pleaded that the Opposite Party still did not pay the claim and moreover, terminated the Health Insurance Policy for suppression of material facts (Ann.C-15 & C-16). Alleging the said repudiation as illegal and deficiency in service, hence this complaint has been filed.

 

2]       The Opposite Party has filed reply and admitted the issuance of Health Insurance Policy in question in favour of the complainant.  The complainant’s sustaining injury on his right thigh on 2.4.2015 during the currency of insurance policy and his taking treatment thereof as well getting the reimbursement for the same from Opposite Party is also admitted.  It is submitted that the complainant had concealed the material fact about his previous ailment of epilepsy and had taken medication in respect of the same, which was a material fact required to be declared at the time of availing of the policy of insurance and which has been purposely hidden by the complainant from the insurance company. Therefore the answering Opposite Party rightly repudiated the claim filed by the complainant as well as terminated the health insurance policy of the complainant on account of suppression of material facts.  Rest of the allegations have been denied with a prayer to dismiss the complaint.

 

3]       Rejoinder has also been filed by the complainant thereby reiterating the assertions made by the complainant and controverting that of the OPs made in their reply.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have also perused the record as well as written arguments.  

 

6]       It is undisputed that the complainant took Health Insurance Policy – Easy Health Floater Standard Two Year Policy from Opposite Party through agency namely Berkeley Retail, Chandigarh, effective from 15.6.2014 to 14.6.2016 and paid an amount of Rs.17,433.97P as premium.  Further, it is not disputed that the complainant is taking Health Insurance Policy since 2010.  It is also not disputed that the complainant met with an accident on 1.4.2015 and got serious injuries on his right thigh and for the treatment of injuries sustained in the accident, the complainant was admitted in Fortis Hospital, Mohali on 2.4.2015 where he was operated upon and Distal Femur Plating was done on right leg, 10 hole distal femur locking plate placed across fracture site and 5 distal and 5 proximal locked done on 3.4.2015.  Admittedly, the complainant was discharged from the Hospital on 6.4.2015 and bill amounting to Rs.2,00,928/- was raised by the Hospital.  It is not denied that out of the said amount, the Opposite Party paid Rs.1,93,673/- and rest of the amount of Rs.7256/- was paid by the complainant. 

 

7]       The matter is also proved that the complainant again fell on floor on 25.4.2015 and sustained injury on the right leg and due to which the screws backed-out of the wound planted by the doctor on 3.4.2015 and old incision plate and fracture site were exposed.  So, the complainant was again taken to Fortis Hospital, Mohali on 26.4.2015 and was again given the treatment such as:-

Fracture reduction done, old plate used and re-adjusted, five distal and five proximal screws placed, bone grafting lefts ASIS taken and grafted over fracture site, wound closure done over negative suction drain, ASD done, Slab applied.  

 

8]      For the said treatment, the Hospital raised bill of Rs.2,05,293/-.

 

9]       It is disputed in the complaint that the complainant had to make the payment of Hospital Bill amounting to Rs.2,05,293/- for the reason that the Opposite Party had refused to honour the request of the complainant for cashless treatment. The complainant vide letter dated 24.5.2015 challenged the cashless denial on which justifying their stand, the counsel for the Opposite Party submitted that the complainant has concealed the material fact about his previous ailment i.e. he is a known case of epilepsy and had also taken medication in respect of the same, but he replied negatively in the proposal form where a specific question had been put to the complainant at the time of availing the policy of insurance.  The Opposite Party vide its letter dated 29.4.2015 terminated the Health Insurance Policy of the complainant for suppression of material facts and thereafter on 5.6.2015 canceled the policy for non-disclosure of material facts. Claimed that the complainant wrongly disclosed that he is not suffering from the disease of epilepsy prior to the taking of the policy of insurance in the Clause 6(V) of the proposal form.

 

10]      It is claimed that the policy of insurance is based on the principle of uberrimae fides and the complainant had entered into the contract on the basis of incorrect information, which the complainant was knowing to be incorrect.  It is further submitted by the ld.Counsel for the Opposite Party that the Opposite Party was right in repudiating the claim of the complainant as he had suppressed/not disclosed material facts about his health to the Opposite Party and as per Section 45 of the Insurance Act, 1938, they are free to rescind the contract. 

 

11]      We are not convinced with the stand taken by the Opposite Party to justify the denial of the benefits under the policy in question.  Since it is proved on record that the complainant is regular policy holder of the Opposite Party since the year 2010 and the Opposite Party had also paid one of the claim under the present policy effective from 15.06.2014 to 14.06.2016 for the treatment of accidental injury caused on the right thigh.  Apparently the second claim was for the sudden fall of the complainant on the floor and sustaining injury on the same leg (right leg), which was earlier treated. 

 

12]      The complainant vide letter dated 24.5.2015 (Ann.C-14) has well explained to the Opposite Party that he is no more patient of epilepsy since he has completely been cured of that disease and is not on any medication since 8 years. The complainant has also appended certificate issued by the treating doctor in this regard, which is placed on record as Ann.C-8.  The contents of the same are reproduced as under:-

          “Patient Mr.Mayank Khosla do not have epilepsy problem now.  Patient had an h/o epilepsy 8 years back but now he is absolutely fine & not taking any medications for epilepsy. Pt. is not taking medications for epilepsy since 8 years.”

 

13]      As it is proved on record that the complainant first availed the Health Insurance Policy in the year 2010 and got the same renewed for further period upto 2016. It is observed that the Opposite Party never ever got done the medical examination of the complainant at the time of issuing the policy for the first time or when the said policy was renewed year after year up till 2016 in order to investigate the truthfulness of disclosures made by the complainant in his proposal form.  This inaction of the Opposite Party shows that the Opposite Party is only interested in blindly issuing the policy in order to collect the premium.  We are of the considered opinion that for the inaction of the Opposite Party, the complainant cannot be made to suffer, who had paid all the premiums with a faith in his mind that he is duly covered under the policy and in time of need, he would be reimbursed by the Insurance Company under the policy availed by him.  Section 45 of the Insurance Act, 1938, which was made the basis of repudiation has wrongly been done by the Opposite Party as section is otherwise applicable in case of life insurance policies and where also the two years period is mentioned for the cancellation of the policy obtained on the basis of concealment or non-disclosure of facts.  This means that the Opposite Party cannot be let free to collect the premiums for the years together and to reject the claim whenever the same is raised taking plea of suppression of material facts. Furthermore, there is no nexus between the epilepsy disease and the accidental injuries sustained by the complainant.  Thus, it is proved that repudiation of claim done by the Opposite Party is unjustified and it amounts to deficiency in service on its part.

  

14]      In view of the above discussion, we are of the opinion that deficiency in service on the part of the Opposite party has been proved and thus, the complaint deserves to be allowed against the OP. Accordingly, the complaint is allowed and the Opposite party is directed as under:-  

a]  To reimburse an amount of Rs.2,05,293/- to the complainant along with interest @9% per annum from the date of cancellation of the policy i.e. 05.06.2015 (Ann.C-16) till realization;

 

b]  To pay an amount of Rs.15,000/- as compensation for causing mental agony and physical harassment to the complainant due to its deficient services;

 

c]  To pay Rs.7,000/- towards litigation expenses.

 

         The above said order shall be complied with by the Opposite party within 45 days of its receipt, failing which it shall be liable to pay interest @18% p.a. on the above awarded amount as per sub-para [a] from the date of cancellation of the policy i.e. 05.06.2015 (Ann.C-16) till it is paid and also on the compensation amounts as at sub-para [b] above from the date of filing this complaint till it is paid, besides paying litigation expenses.

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

05^th Oct., 2016                                                                                                                                                                       Sd/-

 (RAJAN DEWAN)

PRESIDENT

 

 

 

          Sd/-

 (PRITI MALHOTRA)

MEMBER