BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.450 of 2016

Date of Instt. 02.11.2016

Date of Decision: 13.03.2018

Sachin Wadhawa S/o Raj Kumar Wadhawa R/o S-247, Industrial Area, Jalandhar.

..........Complainant

Versus

1. Apollo Munich Health Insurance Company Ltd., Near BMC Chowk, Jalandhar, through its Branch Manager.

2. Apollo Munich Health Insurance Company Ltd., Corporate Office SCF 19, Sector 14, Gurgaon (Haryana), through its Chairman/MV/Authorized Signatories.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before: Sh. Karnail Singh (President)

Smt. Harvimal Dogra (Member)

Present: Sh. Tarun Bajaj, Adv Counsel for the Complainant.

Sh. VK Gupta, Adv Counsel for the OP No.1 and 2.

Order

Karnail Singh (President)

1. This complaint is filed by the complainant, wherein stated that the complainant got one medical health policy/hospitalization benefit policy namely Family Floater Insurance Policy on 29.11.2014, which was covering all the medical expenses of the person insured in case of hospitalization, vide Policy No.180200/11051/AA00160438 from OP No.1, which is Branch Office at Jalandhar of OP No.2. That on 11.12.2015, the complainant felt some pain in his Abdomen and therefore, approached concerned doctor at Nirmal Clinic, Sodal Road, Jalandhar. After his checkup, doctor referred for ultrasound scan. On 16.12.2015, the complainant underwent for whole abdomen scan from Super Scan and Diagnostic Pvt. Ltd., Kapurthala Chowk, Jalandhar and in the said scan, some Hypervascular Hyoerechoic Mass Lesion involving Mid Pols of Left Kidney (Tumor) and a stone in right Kidney was detected. Thereafter, the complainant approached DMC Hospital at Ludhiana on 10.01.2016 for consultation, who referred the complainant for undergoing CT Scan of abdomen, so, the complainant underwent for CT Scan from KAP MRI Centre Pvt. Ltd., Kapurthala Chowk, Jalandhar. In the said scan, some enhancing soft tissue mass mid pol area in the left kidney was detected and a stone in the right kidney was also detected. The complainant was advised by the medical practitioner for removal of left kidney and therefore, the complainant was admitted in National Kidney Hospital, Opp. Sessions Court, Jalandhar, on 25.01.2016 and he was discharged on 29.01.2016, during the hospitalization, left kidney of the complainant was removed. The medical expenses incurred by the complainant were Rs.1,37,298/-, which includes pre-hospitalization charges, hospitalization charges and post-hospitalization charges. Later on, the complainant lodged one application before the OP to claim the above said expenses for the reimbursement of the same along with original bills. Even after lodging a claim along with all original bills, OP again demanded some documents from the complainant and complainant submitted those documents to the satisfaction of the OP. But later on, the claim of the complainant was rejected by the OP on 13.05.2016, arbitrarily and without any reasonable ground by stating that the submitted claim is for the illness, which has a specific period of two years as per policy and your policy start date is 29.11.2014. On 20.05.2016, OP through one letter again sought some additional documents from complainant to arrive at a decision on the same. So, therefore, the complainant deposited those documents required by the OP. On 02.06.2016 and 13.06.2016, the OP sought some more documents from complainant. However, it is worth to mention here that the complainant detected a pain in his abdomen on 11.12.2015 and a tumor was detected in the left kidney on 16.12.2015 after undergoing ultrasound scan. Moreover, the complainant has no history of the same ailment neither he underwent any treatment prior to December 2015 for such ailment.

2. That the complainant also served one legal notice through his advocate to the OP, whereby asked the OP for reimbursement of the claim amount, but till today no reimbursement was made by the OP neither they gave any reply to the said notice, whereby caused a mental harassment to the complainant and there is also a deficiency in service on the part of the OPs and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay the medical expenses of Rs.1,37,298/-, which was incurred on the treatment of the complainant and further OPs be directed to pay a compensation of Rs.1,00,000/- for mental harassment to the complainant and litigation expenses of Rs.15,000/- alongwith interest @ 24% per annum.

3. Notice of the complaint was given to the OPs and accordingly, both the OPs appeared through their 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 Forum with clean hands. The complainant has suppressed various material facts in the present complaint. Hence, the present complaint is liable to be dismissed on this ground only. It is further alleged that there is no deficiency in service or negligence or unfair trade practice on the part of the answering OP and even the complainant has concealed the actual and true facts from the Forum. It is further alleged that on 02.03.2016, a claim was submitted for reimbursement by the complainant for amount of Rs.1,37,298/-. It was noticed from the available documents that the patient was admitted for the management of right upper ureteric stone and follow up case of left renal tumor/mass and underwent PCNL Rt renal and left radical nephrectomy. Later on patient discharged with advice. On the scrutiny of the documents, it was noticed that the provided documents are not upto the line to process the claim and accordingly, for more clarity a query was raised and thereafter, claim was sent for investigation. Post reviewing of the documents, it was noted that disease for which hospitalization was done falls under the two years exclusion condition of the policy. Hence, the claim was rejected, vide letter dated 11.05.2016. On merits, the factum in regard to purchase of insurance policy by the complainant as well as submitting an insurance claim and the same was rejected, is admitted, but the remaining allegations 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.

4. In order to prove the case of the complainant, the complainant himself tendered into evidence his duly sworn affidavit Ex.CA alongwith documents Mark C-1 to Mark C-46 and then closed the evidence.

5. Similarly, counsel for OP No.1 and 2 tendered into evidence affidavit Ex.OP-A alongwith documents Ex.OP-1 to Ex.OP-6 and then closed the evidence on behalf of the OP No.1 and 2.

6. We have heard the learned counsel for the respective parties and also gone through the case file very minutely.

7. After considering the argument of the complainant as well as the OP, we came to conclusion that the factum in regard to purchase of Insurance Policy by the complainant on 29.11.2014 from OP after making a premium of the policy and thereafter, submitted a medical expenditure bill and the same was repudiated by the OP, vide letter dated 13.05.2016, is not in dispute rather the aforesaid entire facts are admitted one.

8. The dispute is only that the medical insurance bill submitted by complainant i.e. Rs.1,37,298/- was repudiated by the OP, vide letter dated 13.05.2016 on the ground that as per Section 6-A (ii) of the terms and conditions of the policy, the complainant is not entitled for the medical insurance claim that as per above provision, a specific two years of waiting period as per the policy is required and policy commenced from 29 November, 2014 and treatment obtained by the complainant on 11.12.2015, regarding that the OP has also brought on the file copy of Insurance Schedule Ex.OP-2 along with the terms and conditions and make much stress on these terms and conditions. Now question remains only whether the term and condition as mentioned in Section 6-A (ii) is applicable in the case of the complainant or not, for that purpose, we have to consider what was the disease to the complainant, for that purpose, the complainant has brought on the file scan of the abdomen, conducted by Super Scanning on 16.12.2015, wherein categorically mentioned as:-

(a). Hypervascular Hyoerechoic Mass Lesion involving Mid Pols of the Left Kidney.

(b). Right sided Hydroureteronephrosis due to Mid Ureteric Calculus.

Similarly, the complainant also got CT Scan Abdomen from KAP Scanning & Diagnostic Centre, Jalandhar, on 13.01.2016, wherein the impression have been shown as:-

(a). Enhancing soft tissue mass mid pole area of left kidney.

(b). Right mid uretric calculus with hydronephrosis.

and then complainant also got Histopath Report from Sardana Labs, Jalandhar and wherein in the opinion, tumor has been also mentioned, it is admitted that a Ureteroscopy Method was done for removal the stone from right kidney, whereas an operation was conducted by National Kidney Hospital for removal of the entire kidney because a tumor has been also shown in the shape of mass lesion with the left kidney and if kidney is open or tumor is separately removed, then there was a chances of spreading a cancer, usually whenever there is a tumor, there are chances of cancer and due to that afraid or apprehension, the left entire kidney was removed along with the tumor and as such, we find that from the treatment of the doctor i.e. National Kidney Hospital itself shows that an operation was conducted and its fee of Rs.41,600/- along with other charges separately in total Rs.90,200/- was taken from the complainant by the National Kidney Hospital and we find that there was apprehension of cancer due to tumor, if so then, the case of the complainant falls under the exception clause given in the referred Section of the term and condition i.e. Section 6-A (ii), wherein exception is as under “except claims payable due to the occurrence of cancer”. So, it is clearly established that the case of the complainant is not covered under the said term and condition rather falls under the exception of that Section. Therefore, we find that the claim of the complainant has been wrongly, illegally repudiated by the OPs, vide repudiation letter dated 13.05.2016, which is null and void.

9. In view of the above detailed discussion, the complaint of the complainant is partly accepted and accordingly, the OPs are directed to pay a medical expenses incurred for treatment i.e. Rs.1,37,298/-, to the complainant with interest @ 9% per annum from the date of repudiation of the claim i.e. 13.05.2016, till realization and further OPs are directed to pay compensation for mental agony and harassment to the complainant, to the tune of Rs.20,000/- and also directed to pay litigation expenses of Rs.5000/-. 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.

10. 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

13.03.2018 Member President