BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.225 of 2017
Date of Instt. 12.07.2017
Date of Decision: 18.12.2018
Raj Kumar age 52 years son of Bansi Lal R/o 5, Netaji Park, Master Tara Singh Nagar, Jalandhar-144001.
..........Complainant
Versus
1. Apollo Munich Health Insurance Company Ltd. Branch Office First Floor Satnam Complex B. M. C. Chowk, Jalandhar- 144001 (Punjab) through its Branch Manager.
2. Apollo Munich Health Insurance Company Ltd. llabs Center, 2nd and 3rd Floor, Flat No.404-405, Udyog Vihar, Phase-Iii, Gurgaon-122016 (Haryana) Through its Authorized Representative/In Charge.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Harvimal Dogra (Member)
Present: Sh. K. C. Malhotra, Adv Counsel for the Complainant.
Sh. V. K. Gupta, Adv Counsel for the OPs.
Order
Karnail Singh (President)
1. This complaint has been filed by the complainant, wherein alleged that the complainant obtained Health Insurance Mediclaim OPTIMA RESTORE FLOATER POLICY for himself as well as for his wife Mrs. Anu Malik and for his son Mr. Karan for insured amount of Rs.3,00,000/- each and the renewal effective period of the insurance was 05.09.2016 to 04.09.2017 and policy number was 180200/11121/AA00280737-01. The complainant has been continuously and uninterruptedly insured himself and his family members for Mediclaim Insurance Policy since year 2015, without any strings with the OP No.1. The total amount of gross renewal premium inclusive of all taxes was Rs.19,490.20 and the same was paid to the OP and which was accepted.
2. That the OP No.1 has 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 Mediclaim Insurance Policy expenses incurred against peril covered under Mediclaim Insurance Policy. That the complainant insured with OP No.1 complained of palpitations i.e. Heart Beat Fast. The complainant was admitted in Care Max Superspeciality Hospital, Jalandhar on 23.01.2017 and discharged on 25.01.2017. The complainant remained under treatment of Dr. Raman Chawla, Consultant Cardiologist. The reason of admission was also given in the Discharge Summary and condition of the complainant at the time of discharge was stable. That after discharge from the Hospital, the complainant lodged a claim in the sum of Rs.33,055/- for Medical Treatment and clinical and laboratory test expenses incurred for reimbursement of expenses to OP. Duly completed prescribed claim forms, bills, receipts discharge certificate along with clinical test were submitted to OPs. All the formalities were completed and complied with for settlement and reimbursement of Mediclaim for full amount of Rs.33,055/-. The claim was registered, vide Claim ID No.519069.
3. That to utter surprise and dismay of the complainant, OP No.2, vide rejection letter dated 01.03.2017 repudiated Mediclaim of the complainant on flimsy and strange purported reason as under:-
“As per the submitted documents, your claim was diagnostic measures in connection with sleep-apnoea, which is excluded from your health insurance policy. Hence, we regret to inform you that your claim is repudiated under Section V C viii (j) of the policy.”
4. The complainant vehemently and specifically deny and dispute that the claim was diagnostic measures in connection with sleep-aponea as projected rather the complainant was treated for palpitations i.e. Heart Beat Fast. OP No.2 has wrongly and perversely rejected Mediclaim of the complainant unilaterally and arbitrarily on whims and fancy. However, no such clause/condition of policy was ever made known to the complainant insured and that policy document containing such purported Exclusion Clause was not even issued and delivered to the complainant during the subsistence of Mediclaim Insurance Policy by renewal and from inception. The rejection of Mediclaim was erroneous and perverse, arbitrary and malafide and the claim was not hit by any such hidden clause/condition was not binding on the complainant in any manner. The OPs could not bind down the complainant to provision of policy of which the complainant was not ever made aware. Cover note/schedule does not specify the terms and conditions governing the policy. This itself a deficiency in service as envisaged under the provision of Consumer Protection Act, 1986.
5. The OPs is guilty of rendering deficient service, negligent and adopted unfair trade practice, which gave a cause of action to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to reimburse the amount of Rs.33,055/- with interest on the date of lodging mediclaim till date of actual payment and further OPs be directed to pay a compensation, to the tune of Rs.10,000/- to the complainant for causing mental tension, agony and harassment and further OPs be directed to pay cost of proceeding of Rs.5000/-.
6. Notice of the complaint was given to the OPs and accordingly, both the OPs appeared through its counsel and filed joint 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 and further averred that the complainant has not approached the Forum with clean hands rather the complainant has suppressed the material facts from the Forum and further alleged that there is no deficiency in service or negligence or unfair trade practice on the part of the answering OP. It is further averred that on 13.02.2017, reimbursement claim was submitted on behalf of the complainant for reimbursement of Rs.33,055/-. It was noticed from the available documents that the patient/complainant was admitted for the management of Diabetes mellitus palpitations, sleep- apnea and underwent sleep study and later on patient discharged with advice. Post scrutiny of the documents, it was noted that the patient was admitted with palpitation during hospitalization he has taken treatment for sleep-apnea and underwent sleep study along with investigation. It was further observed during the hospitalization main management was for sleep-apnea. Sleep-apnea is not covered under the policy, hence the claim was rejected stating and the claim was rightly rejected and further submitted that the disease of sleep-apnea is excluded from the health insurance policy as taken by the complainant and accordingly, the complainant is not entitled for the insurance claim and thus, the same was rightly rejected. On merits, it is admitted that the complainant got insurance policy for himself as well as for his family members and also admitted that the complainant submitted a mediclaim, but the same was rejected on the basis of the terms and conditions. The other averments as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed.
7. In order to prove the case of the complainant, the counsel for the complainant tendered into evidence affidavit of the complainant Ex.CA and supplementary affidavit of the complainant Ex.CB alongwith some documents Ex.C-1 to Ex.C-18 and closed the evidence.
8. Similarly, counsel for the OPs tendered into evidence affidavit Ex.OP-A along with some documents Ex.OP-1 to Ex.OP-5 and closed the evidence.
9. We have heard the argument of learned counsel for the respective parties and also scanned the case file very minutely.
10. From the over all circumstances as put before us, it has become clear that the factum in regard to purchase of insurance policy as well as rejection of the insurance claim by the OP, is not in dispute.
11. Now, question before us is only whether the medi-claim of the complainant has been wrongly rejected by the OP, vide letter dated 01.03.2017 Ex.C-2. In order to analyze the correctness of the said repudiation letter, we have to go through the contents of the said letter just to find out on which ground the medi-claim of the complainant was rejected. The main plea taken by the OP is that the complainant got treatment of sleep-apnea, which is excluded from health insurance policy and accordingly, the claim of the complainant under Section V C viii (j) of the policy was rejected. Admittedly, if the complainant initially got admission in the hospital for treatment of sleep-apnea, then the said exclusion clause is apparently stand applicable in the case of the complainant, but in this case, the complainant was admitted in the Care Max Superspeciality Hospital on 23.01.2017 and discharged there from on 25.01.2017 and treatment was given to the complainant for palpitation and sleep-apnea as elaborated in the summary discharge report Ex.C-5 and further it is clarified by the treating doctor i.e. H. S. Dhingra, vide giving a separate certificate Ex.C-3 that the complainant Raj Kumar Malik was admitted in Care Max Superspeciality Hospital, Jalandhar with palpitations i.e. Heart Beat was fast and accordingly, he was treated for it in the hospital. During the stay in the hospital, it was found that he was obstructive Sleep-Apnea as well. It is clear from the hospital document that initially the complainant was admitted in the hospital for treatment of palpitation i.e. Heart Beat was Fast and he was not admitted for the treatment of Sleep-Apnea, if he was admitted for the treatment of Sleep-Apnea, then question may be different and at that eventuality, the case of the complainant must be covered under the exclusion clause, but if after admission in the hospital for getting treatment of some other disease and later on, one disease discovered, which is come under the exclusion clause, then we cannot cover all the treatment of the complainant/insured within the sphere of exclusion clause and similar situation is in this case, as the complainant was not admitted for treatment of Sleep-Apnea and as such, we find the OP has not carefully considered the case of the complainant for granting of insurance claim rather arbitrarily with a vindictive mind rejected the same without giving a deep thought to the case of the complainant and with these observations, we are of the opinion that the rulings referred by learned counsel for the OP, cited in 2018(1) C. P. J. 109 of Hon'ble National Commission, titled as “Oriental Insurance Co. Ltd Vs. Pratik Samaj Seva Trust and Anr.”, 2017(2) CPR 618 NC, titled as “Ajit Santokchand Surana Vs. National Insurance Co. Ltd., 2017(2) CPR 116 NC, titled as Oriental Insurance Co. Ltd Vs. Rajinder Singh, 2016(4) CLT 456 NC, titled as “M/s Hazaribagh Co. Operative Cold Storage Vs. Universal Sampo Gen. Insu. Co. and Others”, 2010(2) CLT 221 of Our Hon'ble State Commission, titled as “Jyoti Gupra Vs. Oriental Insurance Company Ltd.” and 1995(1) CPJ 218 NC, titled as “New India Assurance Co. Ltd Vs. Nonsuch Tea Estate Limited”, are not applicable in the present case being are not having the similar facts.
12. In the light of above detailed discussion, we came to conclusion that the mediclaim of the complainant has been wrongly repudiated by the OPs and therefore, the repudiation letter dated 01.03.2017 Ex.C-2 is hereby set-aside and further hold that the complainant is entitled for the relief claimed and accordingly, the complaint of the complainant is partly accepted and OPs are directed to pay the medical expenses of Rs.33,055/- to the complainant with interest @ 12% per annum from the date of repudiation letter dated 01.03.2017, till realization and further OPs are directed to pay compensation to the complainant for causing mental harassment, to the tune of Rs.7000/- 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.
13. 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 Harvimal Dogra Karnail Singh
18.12.2018 Member President
