Chandigarh

DF-II

CC/865/2017

Mrs. Ragini - Complainant(s)

Versus

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

Sudhir Gupta Adv. & Rohit Malik Adv.

15 Oct 2018

ORDER

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

Consumer Complaint  No	:	865 of 2017
Date  of  Institution	:	07.11.2017
Date   of   Decision	:	15.10.2018

 

 

 

 

Mrs.Ragini wife of Mr.Tarlochan Singh, aged about 54 years, resident of House No.269, Phase 3-A, Mohali 160059 (Punjab).        

             …..Complainant

Versus

1]  Apollo Munich Health Insurance Company Limited, through its Manager, Chandigarh Branch office, 4^th Floor, SCO No.50-51, Sector 34-A, Chandigarh 160022 (UT)

2]  Apollo Munich Health Insurance Company Limited, through its Manager/Authorised Signatory, 10^th Floor, Building No.10, Tower-B, DLF City, Phase-II, DLF Cyber City, Gurgaon 122002

                          ….. Opposite Parties

BEFORE:  SH.RAJAN DEWAN            PRESIDENT

         SMT.PRITI MALHOTRA        MEMBER

                                SH.RAVINDER SINGH         MEMBER 

 

Argued by: Sh.Sudhir Gupta, Adv. for complainant.

Sh.Pawan Kumar, Adv. proxy for Sh.S.C.Thatai,  

Adv. for OPs.

 

PER PRITI MALHOTRA, MEMBER

 

         The case of the complainant in brief is that she and her husband has taken a Health Insurance Medical Coverage from the Opposite Parties on 18.3.2013. It is averred that the agent of the Opposite Parties got signed blank proposal & others forms from them for providing medical coverage.  It is also averred that the complainant and her husband had to get medical tests done from empanelled hospital/lab of Opposite Parties i.e. Universal Diagnostic Centre, Sector 19-D, Chandigarh and only thereafter, the Opposite Parties issued ‘Optima Restore Insurance Policy’ in favour of the complainant and her husband valid from 23.3.2013 to 22.3.2014.  It is submitted that the said policy was got renewed by the complainant from time to time.

         It is submitted that in Sept., 2016, the complainant suffered from Dengu fever for which a claim was reported to the OPs for treatment and a sum of Rs.48,754/- was paid by the OPs and at that time no ailment of pre-existing disease was found at the Ivy Hospital, Mohali. It is also submitted that on 11.5.2017, the complainant got admitted in Laser Eye Clinic, Sector 22-A, Chandigarh for getting treatment for Cataract Right Eye for which a reimbursement claim of Rs.67,413/- was lodged with the Opposite Parties, but the same was illegally rejected by them vide letter dated 20.7.2017 (Ann.C-10) on flimsy ground claiming that as per medical history she was a known case of diabetics for the last 10 years.  It is also submitted that the Opposite Parties not only rejected the genuine claim of the complainant, but also terminated the policy of insurance in question despite having it renewed for one year from March, 2017 to March, 2018. Alleging the said act & conduct of the OPs as gross deficiency in service and unfair trade practice, hence this complaint has been filed.

 

2]       The Opposite Parties have filed reply and while admitting the factual matrix of the case, stated that the claim of the complainant was received on 2.6.2017, for a total amount of Rs.67,413/- which included consultation, medicine, biometry and cataract surgery. It is stated that during the instigation of medical claim of complainant, it was revealed that the complainant was a known case of diabetic mellitus and hypertension for the last more than 10 years & had been taking treatment in various Hospitals including Post Graduate Institute of Medical Education and Research, Chandigarh.  It is submitted that this fact is also mentioned in a prescription slip issued by Dr. D. Sachdeva, which infact the policyholder did not disclose in the application/proposal form filled for obtaining insurance policy inspite of specific questions asked relating to medical and life style information of insured/proposer.  It is submitted further that since the insured member i.e. Ragini was a known case of diabetic  mellitus & hypertension and since this fact was not disclosed by the complainant in the proposal form dated 18.3.2013, which was material to be disclosed in the said form, therefore, the OPs have rightly repudiated the claim and cancelled the policy as per terms & conditions of the policy. Pleading no deficiency in service and denying other allegations, the Opposite Parties have prayed for dismissal of the complaint.

 

3]       The complainant also filed rejoinder thereby reiterating the assertions as made in the complaint and controverting that of the Opposite Parties made in its 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.

 

6]       It is a proven fact that the husband of the complainant availed Optima Restore Insurance Policy No.110300/11121/6000092516 on 23.3.2013 whereby the complainant is also covered.  Admittedly, after the inception of the policy in the year 2013, the same was continuously renewed and during the subsistence of the coverage period from 23.3.2016 to 22.3.2017 (Ann.C-7), the complainant was reimbursed for the expenses incurred for the treatment of Dengu fever.  The complainant filed the present complaint challenging the repudiation of claim by the Opposite Parties conveyed vide letter dated 20.7.2017 (Ann.C-10), which was lodged for the reimbursement of expenses incurred for Cataract Surgery undergone by the complainant during the coverage period from 23.3.2017 to 22.3.2018 (Ann.C-8).

 

7]       It is the contention of the OPs that since the complainant failed to disclose her  pre-existing disease i.e. Diabetic Mellitus, at the time of inception of the policy i.e. for the first time in the year 2013, thus, not only the claim for reimbursement under challenge has been rejected, but also the policy in question has been cancelled on account of suppression of material facts by the complainant. In our considered opinion, the contention so putforth by the Opposite Parties, is not tenable, for the simple reason that the husband of the complainant when subscribed for the policy of the Opposite Parties covering the complainant as well, both had to subject themselves for thorough medical examination as per requirement of the OPs as is well evident on record.

 

8]       It is observed that it is only on the basis of reports of the medical examination of the proposers as well as on the basis of proposal form filled, the OPs when satisfied, issued the policy in question and thereafter continuously renewed the same, which reflects that at the time of inception of the policy, both the complainant and her husband were hale and hearty and were not suffering from any disease, so alleged by the Opposite Parties.  Since, the complainant and her husband had undergone medical examination before issuance of the policy in question, so no question arises about suppression of fact to be left open to decide.  Further, the rejection of the claim in question by the OPs stating that the complainant is suffering from Diabetes Mellitus since 10 years, has no substantial basis as the OPs had with malafide intention sidelined the information supplied by the treating doctor i.e. Dr.Rajiv Mirchia, whereby it has been so mentioned by the treating doctor that the complainant/patient is a known Diabetic and Hypertensive since 4 years. There is no authentic independent evidence on record placed by the OPs to prove that the complainant is a patient of Diabetes & Hypertension since 10 years, as alleged.  It is wrong on the part of the Opposite Parties to only rely upon the recordings made in the OPD Card of the complainant, whose author has never been examined.

 

9]       In our opinion, the OPs failed to establish on record by any document that the complainant is suffering or is under treatment for Diabetes and Hypertension since 10 years, as alleged.  Therefore, on this ground the rejection made by the Opposite Parties about the genuine claim of the complainant is illegal and not tenable.

 

10]      It is also observed that the complainant has first availed the insurance policy in question in the year 2013 and since then, is getting the same renewed on yearly basis and the Opposite Parties are also enriching themselves by getting the premiums while renewing the policy in question. Further, it is not denied that they had also paid one medi-claim during the subsistence of the coverage period in the year 2016.  Strange enough to think that at one point of time, the OPs are disbursing the claim to the complainant treating the policy to be valid and at the same time they are rejecting the claim for subsequent period under the same renewed policy. This contradictory stand of the Opposite Parties is not acceptable.  Thus, it is held that the complainant is entitled for reimbursement of her claim to the tune of Rs.67,413/- incurred on the treatment during the coverage period.

 

11]      Further, it is pertinent to mention that the complainant has rightly challenged the wrong cancellation of the policy done by the OPs. We are of the view that the cancellation of the policy done by the OPs is totally illegal and arbitrary and also the OPs cannot be allowed to forfeit the right of the complainant/policyholder to get the policy renewed for further period.

 

12]      From the above discussion, it is held that the Opposite Parties have wrongly & illegally rejected the claim of the complainant as well as wrongly cancelled the policy in question, which clearly amounts to gross deficiency in service and unfair trade practice on their part.  Therefore, the present complaint is allowed against the Opposite Parties with following directions:-

1. To reimburse  the claim amount of Rs.67,413/- to the complainant;
2. To restore the policy in question in the name of subscriber/insured with upto date benefits;
3. To pay an amount of Rs.15,000/- as compensation for causing harassment & mental agony to the complainant on account of deficiency in service coupled with unfair trade practice on the part of OPs;
4. To pay an amount of Rs.7000/- towards litigation expenses.

 

         This order be complied with by the OPs within a period of 30 days from the date of receipt of its certified copy, failing which the Opposite Parties shall also be liable to pay additional cost of Rs.20,000/- apart from the above relief.

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

Announced

15^th October, 2018                                                                  Sd/-

                                                                   (RAJAN DEWAN)

PRESIDENT

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER