Chandigarh

DF-I

CC/348/2014

Pardeep Rattan - Complainant(s)

Versus

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

Gaurav Bhardwaj

23 Mar 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

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Consumer Complaint No.	:	CC/348/2014
Date of Institution	:	20/05/2014
Date of Decision	:	23/03/2015

 

 

Pardeep Rattan aged 55 years s/o Sh. Sita Ram Rattan r/o H.No.2934, Sector 37-C, Chandigarh.

…..Complainant

V E R S U S

1.      Apollo Munich Health Insurance Company Ltd., SCO 50-51, 4^th Floor, Sector 34-A, Chandigarh through its Manager.

2.      Apollo Munich Health Insurance Company Ltd., 10^th Floor, Tower-B, Building No.10, DLF, Cuber City, DLF City, Phase-II, Gurgaon, Haryana-122002 through its Managing Director.

……Opposite Parties

 

 

 

QUORUM:	P.L.AHUJA	PRESIDENT
	MRS.SURJEET KAUR	MEMBER

                                               

                                               

                       

ARGUED BY	:	Sh. Gaurav Bhardwaj, Counsel for complainant
		Sh. Nitin Thatai, Counsel for OPs.

                       

                 

PER P.L.AHUJA, PRESIDENT

1.         Sh. Pardeep Rattan, complainant has filed this consumer complaint under Section 12 of the Consumer Protection Act, 1986, against Apollo Munich Health Insurance Company Ltd. and another, Opposite Parties (hereinafter called the OPs), alleging that initially he took medical policy ‘Optima Restore Health Plan’ valid from 7.6.2012 to 6.6.2013 from the OPs. The total sum insured was Rs.3,00,000/- each for the complainant and his wife.  Subsequently, he got the same renewed from the OPs for the period from 17.6.2013 to 16.6.2014. Copies of the policy alongwith terms and conditions and the card issued by the OPs are at Annexure C-1 (colly.), Annexure C-2 (Colly.) and Annexure C-3. 

                According to the complainant, he had an accidental fall inside his house on 10.3.2013 and was unable to move and turn sides.  He was taken to a private clinic and the doctor advised him bed rest and prescribed certain medicines.  The complainant also had some follow up consultations and MRI of his spine was also conducted on 20.3.2014 and after that the doctor advised Vertebroplasty+Biacuplasty+RF slizotomy on 21.3.2014.  The complainant thereafter consulted the Fortis Hospital for the said problem on 22.3.2014 as advised by the doctor. The pre-authorisation form was also filled and sent to the OPs by the hospital as per the terms and conditions.  The total estimated cost of the treatment was Rs.3,10,000/-. The complainant also followed up his case of cashless request with the OPs through e-mails [Annexure C-9 (colly.)] but the same was declined on 26.3.2014 and 28.3.2014 (Annexure C-10 and C-11) on the ground that the ailment for which the treatment is sought comes under 2 year exclusion.  The complainant has contended that he was hale and hearty and had no symptoms of any disease at the time of inception of the policy or its renewal.  Alleging that the aforesaid act amounts to deficiency in service and unfair trade practice on the part of the OPs, the complainant has filed the instant complaint. 

2.         In their joint written reply, OPs have admitted that the policy in question was issued to the complainant and that the same was renewed for the period from 17.6.2013 to 16.6.2014. It has been averred that the policy was issued on the basis of the information furnished in the application/proposal form. It has been denied that the complainant had an accidental fall on 10.3.2013. It has been averred that after reviewing the document, MRI finding and additional documents supplied by the complainant to them there was no fracture and MRI showed degenerating changes. It has been admitted that the complainant applied for pre-authorisation of the treatment and that the cashless facility was declined by the OPs on the basis of two years exclusion clause of the policy documents. It has been contended that the complainant after taking the treatment could have gone for the reimbursement of the claim with proper medical records and the same would have been processed by the OPs as per the merits of the case.  Pleading that there is no deficiency in service or unfair trade practice on their part, OPs have prayed for dismissal of the complaint. 
3.         In his rejoinder, the complainant has controverted the stand of the OPs and reiterated his own.  It has been contended that the complainant fell from stairs and he had deep pain and the doctors advised him vertebroplasty, which is done to stabilize the spinal fractures and to stop the pain caused by fracture.  It has been further contended that the said treatment is not excluded in the policy. 
4.         The parties led evidence in support of their contentions.
5.         After going through the entire evidence, written arguments submitted by both sides and hearing the arguments addressed by the learned Counsel for the parties, we feel that the complaint merits dismissal. 
6.         It is the admitted case of the OPs that he complainant had obtained a policy bearing No.110300/ 11119/6000034616 namely Optima Restore Policy for the period from 7.6.2012 to 6.6.2013 in pursuance of the proposal/application dated 4.6.2012.  Subsequently, the said policy was renewed vide No.110300/11119/ 6000034616-01 commencing from 17.6.2013 to 16.6.2014.  The complainant allegedly had an accidental fall inside his house on 10.3.2013 and after MRI of his spine was conducted on 20.3.2014, the doctor advised Vertebroplasty+ Biacuplasty+RF slizotomy on 21.3.2014. The complainant thereafter consulted the Fortis Hospital for the said problem on 22.3.2014 and a pre-authorisation form was filled up and sent to the OPs by the hospital.  However, the cashless request of the complainant was declined vide email message dated 26.3.2014 (Annexure C-10) on the ground that the etiology of ailment cannot be ruled out and presenting ailment for which the treatment is sought comes under two years exclusion as per the policy terms and conditions.
7.         It is significant to note that the reimbursement claim of the complainant has not been repudiated by the OPs vide email message dated 26.3.2014 (Annexure C-10) because it has been made clear that the cashless denial in no way indicates denial of claim. It is also mentioned that the insured/s are requested to submit their claim documents after completion of treatment for review on admissibility. We are of the view that taking into consideration the circumstances of the case, the present complaint is premature and the complainant has no cause of action to file it merely on the basis of rejection of cashless facility request.  The cashless request was rejected by the OPs because of the fact that as per MRI finding there is no fracture and MRI shows degenerating changes. The OPs have themselves pleaded that the complainant after taking the treatment could have gone for the reimbursement of the claim with proper medical records and the same would have been processed by them as per the merits of the case. We are of the considered opinion that since the claim of the complainant has not been rejected or repudiated on merits, at this stage we do not find any deficiency in service or unfair trade practice on the part of the OPs.  Evidently, if after treatment the reimbursement claim of the complainant is repudiated/rejected, the complainant shall have a right to challenge the action of the OPs.
8.         For the reasons recorded above, the complaint is devoid of any merit.  The same is dismissed leaving the parties to bear their own costs. Needless to mention the observations made in this case shall have no bearing on the merits of the subsequent complaint, if any, regarding this very ailment. 
9.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-
23/3/2015	[Surjeet Kaur]	[P. L. Ahuja]
hg	Member	President