BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No. 366 of 2015
Date of Instt. 26.08.2015
Date of Decision :14.12.2016
Mohinder Pal Singh, son of Sh. Jaimal Singh, resident of 156, Model Town, Jalandhar.
..........Complainant
Versus
Apollo Munich Health Insurance Company Ltd. Branch Office, 1st Floor, Satnam Complex, BMC Chowk, Jalandhar, through its Branch Manager.
Apollo Munich Health Insurance Company Ltd. (Cliam Department), Plot No.277, Udyog Vihar, Phase II-Gurgaon, 122006.
.........Opposite parties
Complaint Under Section 12 of the Consumer Protection Act.
Before: Sh. Karnail Singh, (President),
Sh.Parminder Sharma (Member)
Present: Sh. K.C. Malhotra, Adv., counsel for the Complainant.
Sh. Vikas Kumar Gupta, Adv., counsel for OP No.1 & 2.
Order
Karnail Singh (President)
1. This complaint presented by the complainant, wherein alleged that the complainant obtained Easy Health Insurance Individual policy (hereinafter referred to as Health Insurance Policy), for himself and his wife Mrs. Hargarsh Kaur. The 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 19.11.2014 to 18.11.2015. The first policy inspection date was 18.11.2013. The complainant has been continuously and uninterruptedly insured himself and his wife for Health Insurance Policy since year from 18.11.2013 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.18467.38/- 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 persons without any demur.
2. That 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 to the complainant by opposite party No.1, during the whole period of the policy. It is pertinent to submit that it was mandatory and obligatory upon opposite party No.1 to have issued policy document which expresses the contract of insurance between the insurer i.e. opposite parties and the insured complainant. There is no ground or reason or occasion for not issuing the policy bond. Normally cover note/policy schedule is only interregnum during which policy is prepared and issued. The terms and conditions including exclusion clauses were not ever communicated and explained nor made known to the complainant and were not part of Health Insurance Policy. The opposite parties have agreed and undertaken to indemnify for medical and surgical expenses or illness/sickness, accident and surgical operation etc contracted within the period of insurance to the full extent without any limitation and deduction. Accordingly, the complainant has got the right of indemnification/reimbursement for the whole amount of Health Insurance Policy expenses incurred for any loss or damage or peril covered during the term of Health Insurance Policy. The complainant insured with opposite party No.1, was diagnosed having Mass Soft plate on clinical examination and investigation by Dr. Surinder Sharda M.S. (ENT) Sharda ENT Hospital, Jalandhar. The complainant was advised and was admitted in the said hospital on 07.02.2015 and discharged on 08.02.2015. After discharge from hospital, the complainant preferred a claim in the sum of Rs.10691/- 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, bills, receipts, discharge certificates along with clinical tests and investigations reports were submitted to opposite party No.1 on 05.03.2015. All the formalities were completed and complied with for settlement of Health Insurance Policy claim for an amount of Rs.10691/-. The claim was registered vide claim ID 259671/1. That the opposite party No.2 vide its letter dated 23.05.2015 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 two years waiting period as per the policy and the policy start date is 19.11.2013. Hence we regret to inform you that your claim is repudiated under section VI of the policy”.
3. Opposite party No.2 has wrongly and perversely invoked aforesaid exclusion clause when such clause was neither ever made known/nor explained to the complainant. The rejection of claim was erroneous and perverse when the claim was not hit by any such exclusion clause. There is no specific mention of the illness/disease suffered by the complainant in column illness relating to ENT and treatment therefor. Moreover there is no such column in the proposal form which obligate the complainant to give answer to specific information in such column and as such the rejection of claim was arbitrary and malafide, unjust and oppressive unilateral and illegal which is deficient service, negligence and adopted unfair trade practice in unilateral arbitrary and malafidely repudiation of Health Insurance Policy as envisaged under the Act and as such complainant is entitled for the insurance claim as well as interest and litigation and as such the instant complainant was filed with the prayer that the complaint may be accepted and opposite parties are directed to pay/reimburse Health Insurance Policy claim expenses amount of Rs.10,691/- along with interest @ 12% p.a. from the date of filing of claim till actual payment and further opposite parties may be directed to pay compensation of Rs.50,000/- and litigation expenses Rs.10,000/-.
4. Notice of the complaint was given to the opposite parties and accordingly both the opposite parties appeared through counsel and filed joint written reply, whereby 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 averred that the complainant has not approached this Hon'ble Forum with clean hands rather he is suppressed with the material facts. The facts are that on March 2015, a reimbursement claim was received from Sharda E.N.T. Hospital for patient Mohinder Pal Singh who got admitted with diagnosis of Mass soft palate for which he underwent Excision biopsy with discharge of admission 07.02.2015 and date of discharge 08.02.2015. Total cost of Rs.10,691/-. Post reviewing the documents it was noted that the biopsy report was not submitted by the complainant. In this case biopsy report is important to know the nature of mass i.e. benign or Malignant (Cancerous) So an additional information was called on 25 March, 2015 stating as under:-
I. Kindly provide Biopsy report.
II. Original Cash paid receipt of the final bill.
5. From these documents it was noted that no cancer was detect on biopsy report. Thus it would not be out of place to mention complainant had no cancer hence as per the terms and conditions of the policy, it is relevant to identify whether the nature of ailment falls any of the waiting period or not to determine the admissibility of the said claim. It is thus noted that complainant had undergone diagnosis for Mass soft plate. The term “Mass” as per medical dictionary, which means in medical, a mass effect is the effect of a growing mass that results in secondary pathological effects by pushing on or displacing surrounding tissue. In oncology, the mass typically refers to a tumor, hence it is nothing but tumor which is specifically falls under two years waiting period. For ready reference, it can be seen in the complaint from Section VI. On merits the issuance of insurance policy is admitted but the remaining allegations made in the complaint are categorically denied and as such the complaint may be dismissed.
6. In order to prove his claim, learned counsel for the complainant tendered into evidence affidavit of complainant Ex.CA and further tendered additional supplementary affidavit of the complainant Ex. CB alongwith documents Ex. C1 to Ex. C7 and then closed the evidence.
7. In order to rebut the evidence of the complainant, counsel for opposite party No.1 & 2 tendered into evidence affidavit Ex. OPA alongwith documents Ex. OP-1 to Ex. OP-9 and closed the evidence on behalf of opposite party No. 1 & 2.
8. We have heard the learned counsel for the respective parties and also gone through the case file very minutely.
9. In this case the complainant submitted that he got obtained insurance policy Ex.C3 from the opposite party No.1 for the period 19.11.2014 to 18.11.2015. The complainant also purchase a policy for the period 19.11.2013 to 19.11.2014 and during the insurance of second policy which is continuous of the first policy, the complainant became ill and due to some problem he admitted in Sharda ENT Hospital, Jalandhar for the period 07.02.2015 and discharged on 08.02.2015 and medical expenses are Rs.10,691/- and accordingly the complainant submitted insurance claim Ex.C4. Apart from that the complainant also placed on the file discharge slip Ex.C5, payment receipt Ex.C6 and admission form Ex.C7 but the said claim of the complainant was arbitrary without any reason was repudiated by the opposite parties. The said rejection letter is Ex.C2 and the same is challenged through this complaint on the ground that the complainant was never became aware about the terms and conditions nor any terms and conditions ever applied and as such the claim of the complainant wrongly and illegal repudiated and therefore the complaint may be allowed and in support of this submission the learned counsel for the complainant made reliance pronouncement of Hon'ble State Commission of Punjab cited in 2008 CTJ 769 (CP)(SCDRC), titled New India Assurance Co. Ltd. and Others versus Ravinder Pal Singh. To the contrary, the learned counsel for the opposite parties argue that the claim of the complainant was rightly repudiated because there is exclusion clause in the insurance policy for that purpose. The learned counsel for the OPs referred the terms and conditions of the policy Ex.OP5 wherein such terms and conditions mentioned in Section 6 under the heading waiting period of two years, but the complainant purchase the insurance policy on 19 November, 2013 and submitted the claim on 08.02.2015 means the two years of awaiting period has not completed and as such the claim of the complainant is repudiated in the light of the terms and conditions therefore the same is legal and in support of this submission the learned counsel for the opposite party made reliance pronouncement of Hon'ble National Commission, New Delhi cited in 2012(2) CLT 438, titled Life Insurance Corporation of India Versus Abdul Salim and on the same he further cited an other pronouncement of Hon'ble National Commission, New Delhi cited in 2015(1) CPR 421, titled The New India Assurance Co. Ltd. and Other Versus Nanak Singla and Others. We have carefully considered the above contentions advanced by learned counsel for both the parties and also gone through the relevant terms and conditions as well as pronouncements referred by learned counsel for both the parties and find that the complainant has categorically made allegations in the complaint i.e. para No.3 as the terms and conditions including exclusion clauses were not ever communicated and explained nor made to the complainant and were not part of Health Insurance Policy but the opposite parties could not be able to react this allegation of the complainant by leading any cogent and convenience evidence that when and in what manner the said terms and conditions were applied to the complainant or the same were ever read over to the complainant if so then terms and conditions as referred by counsel for the OPs remained with the office of opposite parties, the same never come to the notice of the complainant, if so then the complainant is not bound by these terms and conditions and therefore this exclusion clause is not applicable on the complainant and thus we find that the claim of the complainant is wrongly and illegally repudiated by the opposite parties and in view of above discussion we find that the judgments referred by the counsel for the opposite parties (Supra) 2015(1) CPR 421, 2012(2) CLT438 are not applicable in the present case being not having identical facts of the case in hand. Whereas the judgment referred by the counsel for the complainant is apparently applicable in this case on the ground that the terms and conditions as well as exclusion clause never applied to the complainant and it was not made known to the complainant and moreover policy is taken by the complainant on yearly basis then there is no logic underlying the condition that total knee replacement is not permissible of 2 years because the yearly policy itself will come to an end on the expiry of a year then the period of 2 years would never reach and this condition itself becomes infructuous and meaningless. So, from these observations, we reach to the conclusion that the complainant is entitled for the relief.
10. Accordingly, the complaint of the complainant is partly accepted and opposite parties are directed to make payment of Rs. 10,691/- with interest @ 9% from the date of filing complaint till realization and further opposite parties are directed to pay compensation for mental tension and harassment to the complainant to the tune of Rs.1500/- and also litigation expenses Rs.1500/-. Compliance be made by the OPs within a period of one month from the receipt of the copy of this order. Complaint could not be decided within stipulated time frame due to rush of work.
11. 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 Parminder Sharma Karnail Singh
14.12.2016 Member President
Mohinder Pal Singh Vs. Apollo Munich Health Insurance.
Present: Sh. K.C. Malhotra, Adv., counsel for the Complainant.
Sh. Vikas Kumar Gupta, Adv., counsel for OP No.1 & 2.
Remaining arguments heard. Vide our separate detailed order of today, the present complaint has been partly accepted. Copies of the order be sent to the parties free of costs under the rules. File be consigned to the record room.
Dated Parminder Sharma Karnail Singh
14.12.2016 Member President
