BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.101 of 2015
Date of Instt. 12.03.2015
Date of Decision : 07.12.2015
Mrs.Renu Gupta wife of Subash Gupta, R/o 235, Lajpat Nagar, Jalandhar.
..........Complainant Versus
1. Apollo Munich Health Insurance Company Limited, Branch Office, 1st Floor, Satnam Complex, BMC Chowk, Jalandhar through its Branch Manager.
2. Apollo Munich Health Insurance Company Limited (Claim Department), Plot No.277, Udyog Vihar, Phase-II, Gurgaon-122006.
.........Opposite parties.
Complaint Under Section 12 of the Consumer Protection Act.
Before: S. Jaspal Singh Bhatia (President)
Ms. Jyotsna Thatai (Member)
Sh.Parminder Sharma (Member)
Present: Sh.KC Malhotra Adv., counsel for complainant.
Sh.VK Gupta Adv., counsel for opposite parties.
Order
J.S.Bhatia (President)
1. The complainant has filed the present complaint under section 12 of the Consumer Protection Act, against the opposite parties on the averments that the law abiding citizen/complainant above named conscious to the need of health insurance allured by tempting benefits obtained Easy Health Insurance Individual (Standard) Policy, for herself. Health insurance policy covered risk to reimburse/indemnify expenses for any disease contracted or suffered from any illness/ailments/disease or injury sustained by the insured person. The health insurance policy was taken from opposite party No.1 through its authorized agent for the period stated in the policy schedule by renewal effective from 29.11.2013 to 28.11.2014. The complainant has been continuously and uninterruptedly insured herself from health insurance policy since year from 29.11.2012 without any gap/break and strings by opposite party No.1. The policy schedule of health insurance policy was issued in the name of the complainant/insured. The total amount of renewal premium of Rs.15,126.42/- as consideration was paid to opposite party No.1, through its agent/representative which was accepted after fully satisfying continued insurability and without questioning the credentials of the insured person without any demur. Opposite party No.1 issued/delivered to the complainant policy schedule only from the inception of the risk coverage under health insurance policy and on its renewal. The policy document was not ever issued/delivered to the complainant by opposite party No.1. The complainant insured with opposite party No.1, complained pain in back going towards leg and weakness and consulted Fortis Hospital, Mohali where all the relevant investigations were done. The diagnosis and MRI revealed LES with L 4-5 Listhesis. She was advised and was admitted in the said hospital on 28.10.2014 and discharged on 4.11.2014. L4 Laminectomy + L4-5 Transpedicula Fixation was done on 29.10.2014. After discharge from hospital, the complainant preferred a claim in the sum of Rs.2,74,229/- for medical treatment and clinical and laboratory test investigation and surgical treatment expenses incurred for reimbursement of hospitalization to opposite parties. Duly completed prescribed, claim form dated 10.11.2014, bills, receipts, discharge certificates reports were submitted to opposite parties. All the formalities were completed and complied with for settlement of health insurance policy claim for an amount of Rs.2,74,229/-. The claim was registered vide claim ID 232563. Opposite party No.2 vide its letter dated 7.1.2015 rejected the claim. In the said rejection letter it was mentioned that the claim is not payable under the policy on purported reasons:-
“The submitted claim is for the illness which has a specific section VI (A) 2 years of waiting period as per the policy and the policy start date is 29.11.2012. Hence we regret to inform you that your claim is repudiated under the policy”.
2. Opposite party No.1 has wrongly perversely invoked aforesaid exclusion clause when such clause was not ever made known to the complainant. The rejection of claim was erroneous and perverse when the claim was not hit by any such exclusion clause. On such like averments, the complainant has prayed for directing the opposite party insurance company to pay her the claim amount of Rs.2,74,229/- alongwith interest. She has also claimed damages and litigation expenses.
3. Upon notice, opposite parties appeared and filed a written reply raising preliminary objections regarding complaint being frivolous and vexatious, not approaching the Forum with clean hands and suppression of material facts etc. They further pleaded that the complainant has concealed the actual and true facts from this Forum and has stated totally wrong facts. It is submitted that actually complainant/member submitted her documents for reimbursement on 12.11.2014. From the submitted documents it was noted that the patient/complainant was admitted on 28.10.2014 with complaints of lower back pain radiating to right left for past one year with history of claudication (cramping pain in the leg) and pain on standing. Complainant/patient is also a known case of Hypertension and Hypothyroidism. She was investigated and diagnosed as a case of LCS with L4-5 with listhesis. For which she underwent L4 Laminectomy + L4-5 Transpedicular Fixation done on 29.10.2014. Post procedure was uneventful and the patient was discharged on 4.11.2014. Post scrutiny of claim documents, it was noted that the policy is in second running year and the disease/illness falls under the waiting period of 2 years for specific illness. Hence the claim merits repudiation. The same was communicated to the member through their rejection letter dated 7.1.2015:-
“The submitted claim is for the illness which has a specific section VI(A) 2 years of waiting period as per the policy and the policy start date is 29 Nov 2012. Hence we regret to inform you that your claim is repudiated under of the policy”.
Orthopedic | Non infective arthritis Gout and Rheumatism Osteoarthritis and Osteoporosis | Surgery for prolapsed inter vertebral disk Join replacement surgeries. |
4. On account of observations given above the claim of the complainant was refused by the opposite parties. From the facts stated above it is clear that there is no deficiency in service on the part of the opposite parties, hence claim of the complainant was rightly refused.
5. In support of her complaint, complainant has tendered into evidence affidavits Ex.CA and Ex.CB alongwith copies of documents Ex.C1 to Ex.C32 and closed evidence.
6. On the other hand, learned counsel for the opposite parties has tendered affidavit Ex.OP-A alongwith documents Ex.OP1 to Ex.OP5 and closed evidence.
6. We have carefully gone through the record and also heard the learned counsels for the parties.
7. The complainant was admitted in the hospital during the validity of the insurance policy and was diagnosed as a case of LCS with L4-5 with listhesis for which she underwent surgery. After discharge from the hospital on 4.11.2014, the complainant submitted claim with the opposite party insurance company but the same was rejected by it vide letter dated 7.1.2015 Ex.C1 on the ground that the above aliment has a specific waiting period under section VI(A) of 2 years and whereas the policy stated on 29.11.2012. So the main question which fall for determination is, whether the above said ailment for which the complainant was admitted in hospital and was operated upon falls under above said exclusion clause? Counsel for the complainant contended that the opposite party insurance company has wrongly misinterpreted the exclusion clause. On the other hand, it has been contended by learned counsel for the opposite party insurance company that the disease of the complainant falls under the above said exclusion clause and claim has rightly been repudiated. The terms and conditions of the policy are on record and have been produced by the opposite party insurance company. The opposite party insurance company is relying upon waiting period mention in section VI (A) clause c of which provides as under:-
Sr. No | Organ/Organ System | Illness | Treatment |
C | Orthopedic | Non infective arthritis Gout and Rheumatism Osteoarthritis and Osteoporosis | Surgery for prolapsed inter vertebral disk Joint replacement surgeries. |
8. Ex.C10 is report of Fortis Hospital, Mohali wherein it is mentioned as under:-
“X-ray Lumbar Spine Lat Flex/Ent
X-ray with the above mentioned patient details and side markers submitted for interpretation.
Anterolisthesis of L4 over L5 over S1 Degenerative changes in spine.
Vertebral bodies, pediclcs and posterior elements appear normal.
No evident abnormal lytic or sclerotic foci are seen.
The inter vertebral disc spaces appear normal.
Pre vertebral soft tissue shadows appear normal”.
9. Ex.C20 is MRI report of Fortis Hospital, Mohali. The observations given in this report are as under:-
“Observations:-
There is loss of lumbar lordosis with straightening of curvature of the spine.
Sacralisation of L5 vertebral body noted.
Grade 1 anterolisthesis of L4 over L5 and L5 over S1 is noted.
Mild anterior wedging of D12 vertebra noted.
Degenerative changes are seen in the vertebrae with endplate osteophyte formation at multiple levels.
The vertebral bodies and posterior elements otherwise show normal alignment, size, shape and signal intensity. No evidence of abnormal marrow signal alteration/bony destruction.
All lumbar intervertebral discs show evidence of desiccation as suggested by loss of bright signal of nucleus pulposus on T2w images and decrease height of L4-5 intervertabral disc.
L5-S1 disc shows diffuse disc bulge without indentation to thecal sac.
L4-5 disc shows diffuse disc bulge with mild indentation of thecal sac and severely compromising the bilateral neural foramina and lateral recesses. Canal diameter is 8.9mm at this level.
L3-4 disc shows diffuse disc bulge with mild indentation of thecal sac and mildly compromising the bilateral neural foramina (R>L). Ligamentum flavum hypertrophy is noted at this level.
L1-2 & L2-3 discs show diffuse disc bulge without indentation of thecal sac and mild narrowing of bilateral neural foramina.
The lower cord, conus, cauda equina appear normal. The paraspinal soft tissues appear normal”.
10. The complainant has produced certificate Ex.C5 wherein it is mentioned as under:-
“To whom it may concern”
Re:- Patient Mrs.Renu Gupta-VHID498317
This is to certify that the above mentioned patient has undergone L4-5 Decompression and instrumented fusion. The above procedure is not included in the list of orthopedic operation serial No.C of the Apollo Munich Insurance Company.
This procedure is generally done by Neurosurgeons and hence she has been operated in Neurosurgery Department of Fortis Hospital, Mohali by myself.
Sd/-
Dr.Ashish Pathak”.
11. So the above said hospital has given specific report that above procedure is not included in the exclusion clause mentioned at serial No.c of section VI(A). On the other hand, opposite party insurance company has not given any specific medical opinion that the procedure done on the patient i.e. insured falls under the above said clause c of section VI. The opposite party is relying upon affidavit Ex.OPA of Deepti Rustagi, Vide President-Legal and Compliance of opposite party company. The person giving affidavit Ex.OPA is simply Vice President-Legal and not medically qualified person. So we have no reasons to disbelieve the certificate Ex.C5 given by Fortis Hospital, Mohali that the procedure done on the patient is not included in the list of orthopedic operation mentioned at serial No.c of above said section VI. In the above circumstances we are of the opinion that opposite party insurance company has wrongly repudiated the claim of the complainant after relying the above said exclusion clause.
12. In view of above discussion, the present complaint is accepted and opposite party insurance company is directed to pay the claim amount of Rs.2,74,229/- alongwith interest @9% per annum from the date of repudiation of claim of the complainant till the date of payment. It is clarified that interest amount is being granted as compensation. The complainant is also awarded Rs.3000/- on account of litigation expenses. Copies of the order be sent to the parties free of costs under rules. File be consigned to the record room.
Dated Parminder Sharma Jyotsna Thatai Jaspal Singh Bhatia
07.12.2015 Member Member President
