Haryana

Karnal

CC/134/2018

Shakti Kumar - Complainant(s)

Versus

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

Mukesh Gorsi

19 Jul 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                             Complaint No.134 of 2018

                                                         Date of instt. 01.06.2018

                                                         Date of decision:19.07.2019

 

Shakti Kumar son of Shri Madan Lal age 29 years, resident of village Brass, District Karnal c/o Hari Pesticides opp. Shiv Mandir Nissing, District Karnal.

…….Complainant       

                                        Versus

 

1. Apollo Munich Health Insurance Company Ltd., 2^nd & 3^rd floor, ILABS Centre, plot no.404-405, Udyog Vihar, Phase-III, Gurgaon-122016 Haryana through its Manager/Authorized person.

2. Apollo Munich Health Insurance Company Ltd., Apollo Hospitals Complex, Jubilee Hills, Hyderabad-500022, Andhra Pradesh through it’s the Managing Director/Authorized person.

3. Apollo Munich Health Insurance Company Ltd., shop no.103, 2^nd floor Mugal Canal, Karnal through its Manager.

4. Canara Bank, opposite Bijli Board Nissing, District Karnal through its Manager.

…..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act.            

 

Before   Sh. Jaswant Singh……President.       

      Sh.Vineet Kaushik ………..Member

              Dr. Rekha Chaudhary……Member

 

 Present   Shri Mukesh Gorshi Advocate for complainant.

                Shri Akshat Sharma Advocate for OPs no.1 to 3.

                Shri Pardeep Kapoor Advocate for OP no.4.

               

                (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 complainant has taken a Parents Plan (Group Assurance Health Plan) Health Insurance Care Policy for himself, his father Madan Lal and his mother Sunita from OPs bearing policy no.120100/12586/2-17/A007873/PE00609674 for Rs.2,00,000/- at a premium of Rs.11,629/- valid from 00.000 Hrs on 1.8.2017 to 24.00 Hrs. on 31.07.2018. After getting the said policy father of the complainant namely Madan Lal become ill and he had been got admitted in Amrit Dhara Hospital, ITI Chowk, Karnal and he got admitted and treated in the said hospital from 14.08.2017 to 17.08.2017 and further admitted on 17.08.2017 in Medanta The Medicity Hospital Gurugram and discharge on 21.08.2017. The father of the complainant was covered under the aforesaid policy which is a cashless policy as such complainant duly intimated the concerned office of OPs for payment to the hospital being cashless policy but the complainant was surprised to receive the letter dated 18.08.2017 “Denial of Cashless Services” wherein OP has refused cashless request of the complainant. Due to denial of the cashless request by the OPs, the complainant made the payment of entire treatment, test medicine etc. of his father from his own pocked and he has spent about Rs.7,00,000/- on the treatment, transportation, diet etc. But unfortunate, the life of the father of the complainant was not saved and he has been expired on 21.08.2017. Thereafter, complainant approached the OPs and submitted entire requisite documents for getting the claim and requested to make the payment of amount which the complainant spent on the treatment of his father but OPs did not pay any heed to the request of complainant and lastly rejected the claim of the complainant on the 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, OPs no.1 to 3 appeared and filed their written version raising preliminary objections with regard to cause of action: complainant is estopped by his own act and conduct and concealment of true and material facts. On merits, it is pleaded that complainant had taken policy for his father and mother only not himself. Its further pleaded that OPs no.1 to 3 are legally bound by the terms and conditions of the policy. Infact, the policy was taken by complainant through OP no.4 on 1.8.2017 after reading and accepting the terms and conditions. It is further pleaded that the cashless request was received on 18.8.2017, Shri Madan Lal was admitted on 17.08.2017 with the complaint of Drowsiness, altered sensorium, Right upper limb cellulitis since 9 days. On scrutiny of the documents it was noticed that admission was done on 17^th day of taking of the policy (policy taken on 1.8.2017) thus the same was falling within 30 days of obtaining the policy and hence the claim was rejected. It is further pleaded that as per section 5(A)(i) of the policy, illness of the patient falls under waiting period of 30 days from the inception of the policy. The contents of section 5(A)(i) of the policy are reproduce as under:-

        Section 5 Exclusions

A      Waiting Periods

        All illness, treatments and their associated complications shall be covered subject to the waiting period specified below:

i)      We are not liable for any claim arising due to condition for which appearance of signs/symptoms, consultation, investigation, treatment or admission started within 30 days from Policy Commencement Date, except for the claims arising due to an Accident.

Hence there is no deficiency in service on the part of the OPs no.1 to 3 in repudiating the claim of the complainant. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             OP no.4 appeared and filed its separate written version raising preliminary objections with regard to maintainability; locus standi; cause of action and concealment of true and material facts. On merits, it is pleaded that the complainant had taken policy namely Group Assurance Health Plan for his father and mother from OPs no.1 to 3 through OP no.4 on 1.8.2017 and there was tie up of the OP no.4 with OPs no.1 to 3 and the complainant paid the premium of the policy. The complainant and OPs no.1 to 3 are bound by the terms and conditions of the policy. It is further pleaded that father of complainant was admitted in the hospital on 17.08.2017 i.e. within 17 days of taking of policy and the same was falling within waiting period of 30 days of obtaining the policy and OPs no.1 to 3 had repudiated the claim of the complainant in consonance with section 5(A) of the policy. The complainant has no right to claim any compensation from OP no.4. There is no deficiency in service on the part of the OP no.4 and prayed for dismissal of the complaint.

4.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C130 and closed the evidence on 1.4.2019.

5.             On the other hand, OPs no.1 to 3 tendered into evidence affidavit of Deepti Rustagi Ex.RW1/A and documents Ex.R1 to Ex.R4 and closed the evidence on 15.05.2019.

6.             OP no.4 tendered into evidence affidavit of Mandeep Singh Branch Manager Ex.RW4/A and document Ex.R4/A and closed the evidence on 3.7.2019.

7.             We have heard the learned counsel of both the parties and perused the case file carefully and have also gone through the evidence led by the parties.

8.             The case of the complainant is that he has taken a Parents Plan (Group Assurance Health Plan) Health Insurance Care Policy for himself, his father Madan Lal and his mother Sunita from OPs. The father of the complainant become ill and he had been got admitted in Amrit Dhara My Hospital, ITI Chowk, Karnal and he got admitted and treated in the said hospital from 14.08.2017 to 17.08.2017 and further admitted on 17.08.2017 in Medanta The Medicity Hospital Gurugram and discharge on 21.08.2017. The policy was cashless hence complainant duly intimated the concerned office of OPs for payment to the hospital but OPs sent a letter dated 18.08.2017 “Denial of Cashless Services” wherein OP has refused cashless request of the complainant. Complainant spent about Rs.7,00,000/- on the treatment of his father. Thereafter, complainant approached the OPs and submitted entire requisite documents for getting the claim but OPs did not pay the claim and rejected the claim of the complainant on the baseless ground.

9.             On the other hand, the case of the OPs is that the complainant has taken a Parents Plan (Group Assurance Health Plan) for his father and mother on 1.8.2017. The father of complainant was admitted in the hospital on 17.08.2017 i.e. within 17 days of taking of policy and the same was falling within waiting period of 30 days of obtaining the policy and OPs no.1 to 3 had repudiated the claim of the complainant in consonance with section 5(A) of the policy. The OPs relied upon the various authorities i.e. Authority under Yeshashwini Wima Yojna Vs. Mumtaz Begum RPII73/2007;General Assurance Society Ltd. Vs. Chandumull Jain and Another, reported in (1966) 3 SCR 500; AIR 1999 SC 3252-Oriental Insurance Co. Ltd. Vs. Sony Cheriyam and Appeal no.6277 of 2004 titled United India Insurance Co. Ltd. Vs. Harchand Rai Chandan Lal decided on 24.09.2004.

10.           Admittedly, on 1.8.2017 complainant had taken policy, namely Group Assurance Health Plan for his father and mother. Madan Lal, father of the complainant admitted in hospital on 17.8.2017 i.e. within 17 days of taking the policy and same was falling within waiting period i.e. 30 days of obtaining the policy and OPs no.1 to 3 had repudiated the claim of the complainant in consonance with section 5(A)(i) of the policy. The Authorities produced by OPs no.1 to 3 are fully applicable to the present case. So, we are of the firm views that there is no force in the complaint.

11.           Thus, as a sequel to abovesaid discussion, we do not find any merits in the complaint and the same is hereby dismissed. No order as to costs. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:19.07.2019

                                                                       

                                                                  President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

               

        (Vineet Kaushik)          (Dr. Rekha Chaudhary)

            Member                               Member