BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, JALANDHAR

Complaint No.129 of 2017 Date of Instt. 04.05.2017 Date of Decision: 09.03.2021

Raj Kumar, aged 48 years s/o Sh. Jagdish Kumar, R/o House No. 786, Street No. O , Near Corporation Tubewell, Avtar Nagar, Jalandhar 144003 (Punjab)

..........Complainant

Versus

1. Apollo Munich Health Insurance Company Ltd., Branch Office, First Floor Satnam Complex, BMC Chowk, Jalandhar 144001 (Punjab), through its Branch Manager.

2. Apollo Munich Health Insurance Company Ltd., Registered Office Apollo Hospital Complex, Hyderabad-5000033

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before: Sh. Kuljit Singh (President)

Smt. Jyotsna (Member)

Present: Smt. Harleen Kaur, Adv. Counsel for the Complainant.

Sh.Vikas Gupta, Adv. Counsel for the OPs No.1 and 2.

Order

Kuljit Singh (President)

1. The instant complaint has been filed by the complainant, against OPs on the averments that he was taken Health Insurance Policy covered the risk to reimburse/indemnify expenses for any disease contracted or suffered from any illness/ailments/disease or injury sustained by the insured person. The first health insurance policy inception dated 05.08.2013 was taken from OP no.1 through its authorized agent, the policy period from 17.08.2016 to 16.08.2017. The total amount of gross renewal premium of Rs.15,703/- as consideration was paid to OP no.1. OPs issued policy schedule 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. The terms and conditions including exclusion clauses were also not ever communicated and explained to complainant. The OPs have agreed and undertaken to indemnify for medical and surgical expenses or illness/sickness, accident and surgical operation etc contracted within the period of health insurance. On 18^th September 2015 the wife of complainant complained of diminution of vision in her right eye. She was diagnosed to have immature senile cataract in her right eye and was advised cataract surgery for right eye. She was operated with phacoemusfication with intra ocular lens implantation was done on 18^th September 2015 in Thind Eye Hospital Jalandhar. Doctor J.S Thind is Surgeon who performed eye cataract surgery. She was admitted on 18.11.2015 and discharged on 19.11.2015. After discharge from the Hospital, complainant lodged claim for Rs.1,31,651/- incurred for cataract plus Rs.1,651/- incurred for surgical operation charges and expenses for medicines to hospital in cash by the complainant from his own pocket for reimbursement for medical, surgical and medicines expenses incurred for reimbursement of hospitalization and treatment to OPs. OPs vide claim settlement-cum-discharge voucher letter dated 15.07.2016 sought precondition consent for settlement of mediclaim for drastically reduced amount of Rs.46,000/- for full and final settlement of the above claim to fully discharge of their liability, whatsoever related to the above claim against total amount of Rs.1,31,651/- The complainant was slapped with routine rejection letter dated 14.12.2016 that based on the claim based on the documents, the claim is not payable under the policy. The repudiation of liability of mediclaim was not germane to the facts and is founded on baseless assumption and speculation and have failed to adopt fairness, transparency human approach. Due to act and conduct of OPs, he has filed the present complaint and prayed that OPs be directed to pay the amount of claim i.e.Rs.1,31,651/-, besides Rs.50,000/- as compensation for mental harassment, Rs.15,00/- as cost of litigation and Rs.11,000/- as cost of proceeding of the complaint.

2. Upon notice, OPs no.1 and 2 appeared and filed their joint written reply and contested the complaint of the complainant by raising preliminary objections that complaint is frivolous, vexatious and devoid of merits. The complainant has suppressed various material facts in the present complaint. The complaint is not maintainable. On merits, it was averred that on 2.10.2015 cashless claim was received from Thind Eye Hospital for patient who got admitted with Diminished Vision in right eye and probable diagnosis of ISC with post lasik right eye with DOA 05.10.2015 and estimated duration of stay of three days and estimated cost of Rs.1,31,500/- The claim was rejected as there was sign of refractive surgery done during the hospital stay through rejection letter dated 14.12.2015. Reminder was sent to the client on 04.04.2016 and on 12.04.2016 but complainant failed to provide the desired information. Hence the claim was closed for want of documents. The claim was reconsidered again with customer centre and it was decided to process the claim by way of discharge voucher. The discharge voucher was sent to the member offering the settlement amount. But the complainant did not provide his consent to process further, so the claim still closed. As per the guidelines of the IRDA the authority regulating the affairs of OPs, the complainant was given detailed description about the features of the said plan including the premium amount to be paid. The terms and conditions were supplied to the insured along with the insurance policy and at the time of taking up the insurance policy. At the request of the complainant, claim was reopened and processed and complainant was offered a settlement amount which is payable as per the terms and conditions of the insurance policy.

3. The complainant has tendered in evidence his affidavit Ex.C-A along with copies of documents Ex.C-1 to Ex.C-13. On the other hand, OPs no.1 and 2 tendered in evidence affidavit of Deepti Rustagi working as Senior Vice President as Ex.OP-A along with copies of documents Ex.OP-1 to Ex.OP-4 and closed the evidence.

4. We have perused written arguments filed by both the parties and have also gone through the record very minutely.

5. The complainant has tendered in evidence his affidavit Ex.C-A in support of his case. Ex.C-B is additional affidavit of complainant Raj Kumar on the record. Ex.C-1 is letter addressed to Manager Apollo Munich Health Insurance regarding not satisfy with claim settlement against claim ID No. 341165. Ex.C-2 is copy of Optima Restore Policy Schedule. Ex.C-3 is copy of claim settlement cum discharge voucher. Ex.C-4 is copy of certificate issued in the name of Sandeep Kaur in which it has been mentioned that she complained of diminution of vision in her right eye. Ex.C-5 is copy of discharge summary of patient Sandeep Kaur. Ex.C-6 is copy of receipt. Ex.C-7 is copy of bill cum receipt. Copies of retail invoice are Ex.C-8 and Ex.C-9 on the record. Ex.C-12 is copy of rejection letter dated 14.12.2015.

6. To refute this evidence of complainant, OPs tendered in evidence affidavit of Deepti Rustagi working as Senior Vice President Legal & Compliance as Ex.OP-A on the record. Ex.OP-1 is copy of power of attorney. Ex.OP-2 is copy of proposal form.

7. It is an established fact that the complainant taken health insurance policy from OP no.1 for the period from 17.08.2016 to 16.08.2017 with premium of Rs.15,703/-. His wife complained of diminution of vision in her right eye. This fact is clear from perusal of certificate Ex.C-4 which has been issued by Thind Eye Hospital wherein it has been mentioned that “ on 18.12.2015 , she complained of diminution of vision in her right eye. She was operated upon right eye for cataract with phacoemulsification with intra ocular lens implanation was done on 18.12.2015 in their hospital”. The complainant spent Rs.1,31,651/- on the treatment of his wife. In document Ex.C-5 discharge summary, it was clear that OP no.1 has charged Rs.1,30,000/- as total from the complainant. Other copies of bill receipts Ex.C-6 to Ex.C-9 are on the record. In rejection letter Ex.C-12, OP no.1 mentioned that claim has been rejected on the ground that laser treatment is not listed in the terms and conditions of the policy. In column no. f of the terms and conditions mentioned that:-

Section IV Special Terms and Conditions :-

The above terms and conditions placed on record by complainant himself as Ex.C-13. From perusal of this document, it is clear that complainant has aware about the same. Both parties are bound by the same and no one wriggle out from the same. The complainant got treatment of cataract from OPs, which is not include in the terms and conditions of the policy. From perusal of document Ex.C-13, it is crystal clear that terms and conditions were supplied to the complainant. In a contract of insurance, rights and obligations are strictly governed by the terms and conditions of the policy.

8. The learned counsel for OPs relied upon various judgments in support of their case :-

1. The case titled as Reliance Life Insurance Company Limited and others versus Rekhaben Nareshbhai Rathod reported in 2019(6) SCC 175 of Hon’ble Supreme Court, wherein it has been held that “non-disclosure of earlier cover. Repudiation of claim. Two months prior to policy obtained from appellant insured obtained policy from another company. Fact not disclosed by insured. Repudiation made within two years period from commencement of insurance cover. Failure of insured to disclose policy of insurance entitled insurer to repudiate claim.”

2. Case titled as M/s Suraj Mal Ram Niwas Oil Mills (P) Ltd versus United India Insurance Company Ltd and another of Hon’ble Supreme Court reported in Civil Appeal No.1375 of 2003 date of decision 08.10.2010 wherein it has been held that “breach of a condition of insurance policy by insured- Insurance not liable to pay claim.”

3. Satwant Kaur Sandhu versus New India Assurance Company Ltd of Hon’ble Supreme Court of India reported in 2009(3) CPC 6 wherein it has been held that “fact suppressed was a material fact – there is no deficiency in service. Insurance company justified in repudiating the claim. Material fact means any fact which would influence the judgment of a prudent insurer in fixing insurer the premium or determining whether to accept the risk or not.”

4. General Assurance Society Ltd. Versus Chandmull Jain and another reported in Civil Appeal No. 886 of 1963 decided on 07.02.1966 of Hon’ble Supreme Court wherein it has been held that “ contract of insurance –Ambiguity – No difference between a contract of insurance there is requirement of uberima fides i.e. good faith on the part of the assured.”

9. From perusal of certificate Ex.C-4, it is clear that wife of the complainant was advised for cataract surgery of right eye, she was operated upon right eye for cataract with Phacoemulsification with Intra Ocular Lens Implantation was done on 18.11.2015 in the hospital. This document clear that wife of the complainant got treatment of cataract surgery of right eye from OPs Hospital and this treatment is not include in the terms and conditions of the policy as per Ex.C-13 placed on the record.

10. In the light of our above discussion, we find no force in the submissions of complainant, therefore, the present complaint is hereby dismissed. Parties are left to bear their own costs.

11. Copies of the order be sent to the parties, as permissible, under the rules.

12. File be indexed and consigned to the record room after due compliance.

Announced in open Commission

9^th of March 2021

Kuljit Singh

(President)

Jyotsna

(Member)