BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.33 of 2016
Date of Instt. 18.01.2016
Date of Decision: 05.02.2019
Sanjay Gulati aged 45 S/o Sh. Dev Raj Gulati Resident of H. No.630R Ward No.54 Jalandhar-144001.
..........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, Gurgaoen- 122006.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Jyotsna (Member)
Present: Sh. K. C. Malhotra, Adv Counsel for the Complainant.
Sh. Vikas Kumar Gupta, Adv Counsel for OPs No.1 & 2.
Order
Karnail Singh (President)
1. This complaint has been filed by the complainant, wherein alleged that the complainant had obtained first health insurance policy from OP No.1 with effect from 19.11.2012 and thereafter, the same is getting renewal every year from due date continuously and regularly without any break or gap. The current health insurance policy commenced from 19.11.2015 to 18.11.2016 after paying the premium of Rs.12,373/-. The basic sum insured was Rs.5,00,000/- with multiplier benefit of Rs.3,00,000/- for each insured. It is pertinent to mention that the insurance policy since 2012 has been continuously obtained by the complainant for himself as well as his wife Nishi Gulati.
2. That OP No.1 delivered to the complainant only health insurance policy schedule of the risk coverage. The policy document was never issued to the complainant by OP No.1 during the whole period of health insurance policy since inception and renewal. It is pertinent to submit that it was mandatory and obligatory upon OP No.1 to have issued health insurance policy document which expresses the contract of insurance between insurer i.e. OPs and the insured complainant. There was no ground or reason or occasion for not issuing policy bond. The terms and conditions including clauses were not ever explained and communicated nor made known to the complainant and were not part of health insurance policy. The OP is have agreed and undertaking to indemnify for medical and surgical operation expenses etc. or illness/sickness, accident contracted within the period of insurance to the full extent without any limitation and deduction. Accordingly, the complainant has the right to indemnification/reimbursement for the whole of the amount of expenses incurred for any loss or damage or peril during the terms of health insurance policy.
3. That the complainant insured with OPs, was diagnosed as a case of Anal Fistula with Sinanal Pile by City Hospital, Jalandhar after necessary clinical examination and investigation and tests were done. The complainant was advised surgery as soon as possible. The complainant was admitted as a patient on 28.09.2015 and surgery was done on 28.09.2015 and discharged on 29.09.2015.
4. The hospitalization lasted over one day i.e. 26½ hours for treatment for surgical operation and illness suffered and diagnosed by Dr. Satwant Singh, M. S. FAIS Consultant Surgeon of City Hospital, Jalandhar. After discharge from the hospital, the complainant preferred a claim a sum of Rs.29,597/- for surgery and medical treatment and expenses incurred for reimbursement of hospitalization to OPs. Duly completed prescribed Claim Form was submitted on 23.10.2015 along with all relating documents. All the formalities were completed and complied with for settlement and reimbursement of health insurance policy claim for an amount of Rs.29,957/-. But the OP No.2, vide its letter dated 16.12.2015 refused to reimburse claim on flimsy and silly purported pretext and on lame excuse that the complainant known case of Diabetes and Hypertension since 2010, which insured member never disclosed at the time of application for health insurance coverage and gave threatened notice of 30 days of termination of policy from the last renewal date and that the complainant is not entitled for any benefit under the policy and the premium paid by the complainant for the policy period 2015-16 will be refunded. Refusal of the insurance claim and notice of termination of policy and refund of renewal premium for policy period 2015-16 was arbitrary, malafide, unjust and operasive, which is tantamount to deficiency in service on the part of the OPs and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to reimburse the health insurance policy mediclaim expenses in the sum of Rs.29,597/- along with interest @ 12% per annum from the date of submission of mediclaim till its payment and further OPs be directed to pay compensation of Rs.20,000/- and litigation expenses of Rs.5500/-.
5. Notice of the complaint was given to the OPs, who appeared through its counsel and filed joint reply and contested the complaint by taking preliminary objections that the present complaint is frivolous, vexatious and devoid of merits and hence, the same is liable to be dismissed with heavy cost and further submitted that the complainant has suppressed the material facts from the Forum, hence the present complaint is not maintainable because the real facts are that on 23.10.2015, the reimbursement claim of the complainant was received by the answering OP with date of admission 28 September, 2015 and date of discharge 29 September 2015 with final claimed amount of Rs.29,597/-. Then post reviewing the documents it was noted that the patient was admitted with c/o pain in anal region aggravated with constipation, 1 month and External growth along with anal margin present. Difficulty while sitting, 3 days back acute pain with pus anal opening. He was examined and diagnosed as a case of Fistula anus for this fissurectomy was done and the patient was discharged with advice. In order to get clarity and additional information was called from the complainant and out of that, few documents were received and revived. However, in the meantime, it was also initiated for investigation and as per the investigation report, it was noted that the complainant had himself declared that he was a known case of Hypertension and Diabetes Mellitus since 2010. Based on the above facts, the claim was rejected on 17.12.2015 and further notice for terminating of the policy was also given to the complainant. On merits, it is admitted that the complainant obtained the policy since 2012 and it was renewed time to time and claim was also admittedly submitted by the complainant, but the same was repudiated. The other allegations as made in the complaint are categorically denied and lastly sumbitted that the complaint of the complainant is without merits and the same may be dismissed.
6. In order to prove the case of the complainant, counsel for the complainant tendered into evidence affidavits of the complainant Ex.CA and Ex.CB along with some documents Ex.C-1 to Ex.C-7 and closed the evidence.
7. Similarly, counsel for the OPs No.1 and 2 tendered into evidence two affidavits Ex.RA and Ex.RB along with some documents Ex.R-1 to Ex.R-13 and closed the evidence.
8. We have heard the learned counsel for the respective parties and also gone through the case file very minutely.
9. Precisely, the case of the complainant is that he obtained insurance policy on 19.11.2012 from the OP for himself as well as for his wife and the said policy was got renewed every year continuously without any break or gap and the last insurance policy was obtained for the period November 2015 to November 2016 and the insured amount of the policy is Rs.5,00,000/- and further alleged that no document of the policy except the covering note was ever supplied/delivered to the complainant nor made known to the complainant and unfortunately, the complainant became ill and he got diagnosed as a case of Anal Fistula with Sinanal Pile from City Hospital, Jalandhar and he was advised to get surgery and accordingly, he admitted in the hospital on 28.09.2015 and discharged there from on 29.09.2015 by remaining in the hospital for treatment of 26½ hours and thereafter, complainant submitted a medical claim of Rs.29,597/- on 23.10.2015, but the same was repudiated by the OP, vide letter dated 16.12.2015 and also served a notice of 30 days for termination of the policy and accordingly, necessity arose to the complainant to file the instant complaint.
10. The OP has not denied the factum in regard to getting insurance policy since 2012 till 2016 and it is also not denied by the OP that a medico insurance claim was submitted by the complainant rather the OP alleged that the said medico insurance claim of the complainant was repudiated due to the reason the complainant has concealed the pre-existing disease of Hypertension and Diabetes and in order to establish that the complainant was having the aforesaid disease since the day of inception of the insurance policy i.e. prior to 2012, regarding that the OP has brought on the file only one document i.e. the alleged admission of the complainant, vide document Ex.R-8 and on the basis of said document, the claim of the complainant were rejected and also notice was served to the complainant that he misrepresent the insurance company and why your insurance policy is not to be cancelled and accordingly, the same was cancelled on 28.01.2016, vide letter Ex.R-13.
11. Now, we have to analyze whether the admission of the complainant itself sufficient that the complainant is suffering from the disease of Hypertension and Diabetes since 2010, we find that the disease of Hypertension and Diabetes is curable after taking a proper medicine. It is not such like a disease, which remain whole of the life. Simply bringing on the file photostat copy of the one document alleging that it is admission of the complainant, is not sufficient because the insurance company in routine whenever issue insurance policy to any person having the age of above 40 years, get medical examination of said insured person, but the date of birth of the complainant is March 1970 and he obtained the insurance policy on 19.11.2012 first time, means at that time the complainant was over and above of 40 years and thereafter, continuously the complainant got renewed insurance policy since 2015, but the insurance company did not bother to get medical examination of the complainant in order to ascertain whether he was having any disease or not. It is not established on the file that the complainant is taking any medicine of the disease Hypertension and Diabetes, if so, then simply writing on one paper and alleging it is a confession of the complainant is not sufficient to prove that the complainant has any pre-existing disease. So, with these observations, we are of the opinion that the medical insurance claim of the complainant has wrongly and illegally repudiated by the OPs and the same is set-aside and accordingly, the complaint of the complainant is partly accepted and OPs are directed to pay medi-claim expenses of Rs.29,597/- to the complainant with interest @ 12% per annum from the date of repudiation i.e. 16.12.2015, till its realization and further OPs are directed to pay compensation for causing mental tension and harassment to the complainant, to the tune of Rs.10,000/- and litigation expenses of Rs.3000/-. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
12. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jyotsna Karnail Singh
05.02.2019 Member President
