Punjab

Ludhiana

CC/19/531

Balwinder Singh - Complainant(s)

Versus

Apollo Munich Health Insurance - Opp.Party(s)

S.S.Heer Adv.

09 Jan 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 531 dated 19.11.2019.       

                                                Date of decision: 09.01.2023. 

 

Balwinder Singh aged about 53 years s/o. S. Harnam Singh, r/o. House No.1167/1, Ward No.38, Mohalla Taj Ganj, Samrala Road, Near Baba Than Singh Chowk, Ludhiana-141008, Mobile No.94175-95505.                                                                                                           ..…Complainant

                                                Versus

1. HDFC Ergo General Insurance Company Ltd., 2^nd & 3^rd Floor, ILABS Centre, Pot No.404-405, Udyog Vihar, Phase III, Gurugram-122016, through its Managing Director.
2. Apollo Munich Health Insurance Company Ltd., Registered office at Apollo Hospitals Complex, Jublee Hills, Hyderabad-500033, Telangana known as HDFC Ergo General Insurance Company Ltd.                   
3. Apollo Munich Heath Insurance Company Ltd., SCO-146, 2^nd Floor, Ferozegandhi Market, Upstairs ICICI Bank Ltd., Ferozepur Road, Ludhiana, through its Branch Manager known as HDFC Ergo General Insurance Company Ltd.                                                                                                                                                         …..Opposite parties

Complaint Under Section

12 & 14 of the Consumer Protection Act, 1986.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. S.S. Heer, Advocate.

For OPs                         :         Sh. Ajay Chawla, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                In brief, the facts of the case are that the complainant being resident of House No.1167/1, Mohala Taj Ganj, Ward No.38, Samrala Road, Near Baba Than Singh Chowk, Ludhiana purchased policy No.110600/11/001/1000063585-10 through intermediary Jaswinder Kaur in which previous policy insufficient date 04.02.2010 is mentioned. Opposite party No.1 vide this letter dated 31.03.2019 has sent new policy kit for the period 28.03.2019 to 27.03.2020 with total sum insured of Rs.6,00,000/- against premium of Rs.18,220.73, particulars of which are reproduced as under:-

Sr. No.	Name	Relationship	Sex	Age years	Sum Insured
1.	Balwinder Singh	Policy holder	M	53	2,00,000/-
2.	Jaspleen Kaur	Wife	F	46	2,00,000/-
3.	Jasjeet Singh	Son	M	24	1,00,000/-
4.	Rasmeet Singh	Son	M	22	1,00,000/-

 

The complainant submitted that his son namely Jasjeet Singh covered under USID No.10000775384 has suffered with the problem Diminution of vision in his both eyes and was admitted with Thind Eye Hospital Ltd., 701, Model Town, Jalandhar for the treatment of said problem vide registration No.588487 . On examination, his UCVA was finger counting at 1 Meter in both eyes and BCVA was 6.6 in right eye with-8.00/Dsph – 0.50/Dcyl 100/axis and 6/6 in left eye with – 7.50/Dsph – 1.50/Dcy 150/axis. His anterior and posterior segment was within normal limits and intra ocular pressure was also within normal limits. He was diagnosed to have high myopia in his both eyes and was advised to undergo i lasik with custom vue. The laser treatment was done on 31.01.2019 in the said hospital which cost him Rs.80,000/- which the complainant paid vide bill No.JAL/18-19/59/346 dated 31.01.2019 towards the Lasik with custom vue charges. After his discharge, the complainant submitted claim for settlement of cashless claim/reimbursement of the bill amount along with requisite documents with the opposite parties. The opposite parties have registered the claim vide claim ID No.949979. Thereafter, the complainant contacted the opposite parties for the reimbursement of the claim amount but the opposite parties did not give any proper reply and lingered on the matter on one pretext or the other. The complainant was surprised to receive a letter dated 14.11.2019 vide which the claim of the complainant was repudiated with the reasons, ‘The submitted claim is for correction of refractive error using laser treatment. Laser treatment for correction of refractive error is specifically excluded in the policy. Hence be regret to inform you that your claim has been repudiated under Section VICx of policy.’ The repudiation of the claim vide letter dated 14.11.2019 is totally illegal, null and void, arbitrary, malafide and against the terms and conditions of the policy on the reasons reproduced as under:-

1. That the opposite parties have not explained the terms and conditions to the complainant at the time of purchase of policy which has been removed against the previous policy which is continuously renewed since 04.02.2010.
2. That no policy along with terms and conditions have been supplied to the complainant till today by the opposite parties. Only the policy renewal kit has been supplied to the complainant vide their letter dated 31.03.2019.
3. That the above said policy has been issued to the complainant after the receipt of the premium and the same is valid w.e.f. 28.03.2019 to 27.03.2020.
4. That the cover note supplied to the complainant has only three pages and there is no such clause in the said cover note as alleged by the opposite parties in their letter dated 31.03.2019.
5. That the complainant has submitted the claim for the settlement of the cashless claim along with mandatory documents as required by the opposite parties and the same has been registered with the opposite, parties vide claim UID No.949979.
6. That there is a discrimination on the part of the opposite parties as they have already settled the similar claim of Ms. Neha Bansal d/o. Rakesh Bansal, r/o.18-A, Aggar Nagar, Ludhiana who remained admitted in the same hospital with the son of the complainant, claim of which is No.1904905 having bill cum receipt for Rs.1,27,000/-.
7. That the police number in rejection letter dated 14.11.2019 has been wrongly mentioned as 1100600/110001/1000063585-09 instead of 1100600/110001/1000063585-10.

The complainant has further submitted that he has suffered mental pain and agony due to negligence and deficiency in service on the part of the opposite parties. In the end, the complainant has sought direction to the opposite parties to pay the claim amount of Rs.80,000/- along with compensation of Rs.20,000/- besides litigation expenses.

2.                Upon notice, the opposite parties appeared and filed joint written statement by taking preliminary objections that Apollo Munich Health Insurance Company Limited has been renamed as HDFC Ergo Health Insurance Limited w.e.f. 09.01.2020 under the Companies Act, 1956. The opposite parties further took preliminary objections that the complainant complaint is an abuse of process of law and has been filed with intention to harass and pressurize the opposite parties. The complaint is based on frivolous and baseless facts with nefarious designs. The complaint is barred by the Section 3 of the Consumer Protection Act, 1986. The claim raised by the complainant falls under the exclusion clause as per terms of the policy and as such, no benefit is payable to the complainant for the subject claim raised by him as on the review of the documents submitted by the complainant for reimbursement, it was found that the insured was admitted for laser treatment for correction of refractive error and same is specifically excluded in the policy. Repudiation of the claim of the complainant is justified as per Section VI(C) of the policy. The complaint has been filed to extort money from the opposite parties and the complainant has not approached this Commission with clean hands.

                   Under the column brief facts of the case, the opposite parties have submitted that the complainant approached them for availing insurance policy and submitted proposal form No.1100371605 dated 04.02.2010 for issuance of an insurance policy namely Easy Health Individual Standard Policy for providing an insurance cover for himself and his family. As per the proposal form, the opposite parties issued a policy No. 110600/11001/1000063585 on 04.02.2010 which was renewed from time to time. The policy kit containing all the relevant documents were duly sent to the complainant giving free look period of 15 days from the receipt of the policy documents to review the terms and contract of the policy. The complainant raised no objection within the free look period and as such, he is strictly bound by the terms and conditions of the policy. On 13.02.2019, claim for reimbursement was received from the complainant/patient who got admitted on 31.01.2019 at Thind Eye Hospital for treatment of both eye lasik surgery under local anesthesia and got discharge on same day for his myopic conditions (refractive error) with final diagnosis DIMINUTION OF VISIOIN OF BOTH EYES. On post reviewing the documents, it was noted that the patient was treated with Laser treatment for correction of refractive error which is specifically excluded in the policy and as such, the claim was rejected vide rejection letter dated 16.02.2019 stating: “The submitted claim is for correction of refractive error using laser treatment. Laser treatment for correction of refractive error is specifically excluded in the policy. Hence we regret to inform you that your claim has been Repudiated under Sec-VI C x of policy.” The opposite parties further submitted that as per policy wordings Section VI of the Insurance Policy deals with Special Terms and Conditions of the insurance. Clause C of the same deals with the ‘Genera Exclusions’. Genera Exclusions specify those conditions which are not covered under the policy and for which the insurance company is not liable to pay the claim.

                    On merits, the opposite parties reiterated the facts stated in preliminary objections and brief facts of the case and denied the deficiency of service on their parties. In the end, a prayer for dismissal of the complaint has been made.

3.                During the pendency of the complaint, the opposite parties filed application for substation of company name from HDFC Ergo Heath Insurance Limited (formerly known as Apollo Munich Health Insurance Company Limited) to HDFC Ergo General Insurance Company Limited, which was allowed vide order dated 19.04.2022 and the Reader of this Commission was directed to made necessary amendment in the name of the opposite parties in the head note of the complaint.  

4.                In support of his claim, the complainant tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 is the copy of aadhar card of the complainant, Ex. C2 is the renewal of the policy for the period 28.03.2019 to 27.03.2020, Ex. C3 is the schedule of the policy, Ex. C4 is the discharge summary dated 31.01.2019, Ex. C5 is the bill cum receipt of Rs.80,000/- dated 31.01.2019, Ex. C6 is the rejection letter dated 14.11.2019, Ex. C7 is the copy of indoor bill of Neha Bansal dated 31.01.2019, Ex. C8 is copy of discharge summary of Neha Bansal dated 31.01.2019, Ex. C9 is copy of settlement of claim of Neha Bansal and closed the evidence.  

5.                On the other hand, the counsel for the opposite parties submitted affidavit Ex. OPA of Sh. Manoj Kumar Prajapati, Manager-Corporate Legal in the opposite parties along with documents Annexure-R1 copy of proposal form, Annexure-R2 is copy of policy documents and schedule, Annexure-C is copy of claim form, Annexure-D is the copy of rejection letter dated 16.02.2019 and closed the evidence.

6.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply filed on record by both the parties.

7.                Perusal of record shows that originally, the complainant had purchased the policy bearing No.110600/11/001/1000063585-10 on 04.02.2010 through intermediary Jaswinder Kaur which had been being renewed periodically. Son of the complainant namely Jasjeet Singh complained of Diminution of vision in his both eyes. He was examined at Thind Eye Hospital, Jalandhar and he was diagnosed to have high myopia in his both eyes and was advised to undergo i lasik with custom vue. His laser treatment was done on 31.01.2019 which cost him of Rs.80,000/- all in case. This fact also stands mentioned in discharge summary Ex. C4.

8.                However, the claim of the complainant with regard to reimbursement of aforesaid expenses was repudiated vide letter Annexure-D on the ground that submitted claim is for correction of refractive error using laser treatment which is specifically excluded in the policy as stipulated in Section VI (C) x of policy. The said clause is reproduced as under:-

          Section VI, Special terms and conditions

          C. General Exclusions:

We will not pay for any claim in respect of any insured person directly or indirectly for, caused by, arising from or in any way attributable to:

          Medical Exclusions:

          ix) Treatment for correction of eye sight due to refractive error.

What are the major exclusions of the policy.

Following is a partial list of the policy exclusions. Please refer to the policy wording for the complete list of exclusions. War or any act of war, nuclear and biological weapons, radiation of any kind, breach of law with criminal intent, intentional or attempted suicide, participation or involvement in naval, military or air force operation, racing diving, aviation, scuba diving, parachuting, hang-gliding, rock or mountain climbing, abuse of intoxicants or hallucinogenic substances such as intoxicating drugs and alcohol, treatment of obesity and any weight control program, Psychiatric, mental disorders, congenital external diseases, defects or anomalies, genetic disorders, sleep apnea, expenses arising from HIV or AIDs and related diseases, sterility, treatment to effect or to treat infertility, any fertility, sub-fertility, surrogate or vicarious pregnancy, birth control, circumcisions, laser treatment for correction dye due to refractive error, plastic surgery or cosmetic surgery unless required due to an Accident, Cancer or Burns.

Section VI

 

9.                The counsel for the complainant has contended that the opposite parties have wrongly repudiated the claim of the complainant on false and frivolous grounds. In support of his contentions, the counsel for the complainant has relied upon case title The New India Assurance Company Limited Vs Sippan Jain in First Appeal No.1334 of 2013 decided on 16.03.2015 by Hon’ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh whereby it has been held that the repudiation of the claim of myopia with astigmatism in both eyes, repudiated by the insurance company on the ground that correction of eye sight being a Cosmetic/Aesthetic procedure was not payable under clause 4.4.2 of the policy, was set aside and the complainant was held entitled for the claim. The counsel for the complainant has further relied upon case title Royal Sundaram Alliance Insurance Co. Ltd. Vs Suchi Sethi in First Appeal No.249 of 2013 decided on 08.03.2017 by Hon’ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh. In this case also, the complainant was found to be suffering from myopia for  with astigmatism for which lasic surgery was advised and the claim was repudiated on the ground the lasic surgery was a cosmetic surgery and was excluded under terms of the policy. In this case also, the repudiation of the claim was set aside and the insurance company was directed to pay the claim.

9.                On the other hand, the counsel for the opposite parties has argued that the claim has been rightly repudiated in accordance with the terms and conditions of the policy. He has further contended that the case law relied upon by the counsel for the complainant is not applicable to the facts and circumstances of the present case and further that the complaint is without any merits and deserves to be dismissed.

10.              Now the point of consideration arises whether the opposite parties were justified in repudiating the claim of the complainant by invoking clause VI (C) x of the policy.

11.              As per information available on internet, more particularly www.healthline.com ICL is an implantable collamer lens which is an artificial lens that is permanently implanted in the eye to treat Myopia or Hypropia. It is further mentioned that ICL permanently reduces your dependency on glasses or contact lenses. It is further mentioned on this website that ICL surgery is not necessary to correct the vision problems, but it eliminate or reduce the need for glasses or contact lenses.

12.              If we go by the exclusion clause, any surgery for correction of eye sight due to refractive error is excluded. Refractive error in the eyes means that the shape of the eye does not bend light correctly resulting in blurred image and further in the main types of refractive errors are myopia (nearsightedness), hyperopia (farsightedness), presbyopia (loss of near vision with age) and astigmatism. Therefore, it is evident that the refractive error in the eyes is nothing, but primarily a result of myopia, hyperopia etc. As stated above, ICL surgery which has been carried out upon the complainant is nothing, but a treatment of myopia which is covered under the definition of refractive error and has been expressly excluded under clause VI (C ) x of the policy terms and conditions. Therefore, in our considered view, the claim for any surgery including ICL surgery is covered not under clause VI (C ) x of the policy and was not payable and therefore, the claim has been rightly repudiated.

13.              So far as the law relied upon by the counsel for the complainant is concerned, the same are not applicable to the facts and circumstances of the case. In those citations, treatment of refractive error was not specifically excluded in the terms and conditions of the respective policy itself.

14.              Vide Ex. C2 renewal letter and Ex. C3 policy details, the complainant got the policy renewed having validity for a period from 28.03.2019 to 27.03.2020. It has been stated in the complaint itself that he had received a new policy kit. It is evident from Ex. C3 as well that he was also granted bonus. It cannot be said that the complainant was not supplied with the terms and conditions of the policy and he was not aware of the exclusion clause.

15.              As a result of above discussion, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

16.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)                             (Sanjeev Batra)

 Member                                  President

 

Announced in Open Commission.

Dated:09.01.2023.

Gobind Ram.

 

 

Balwinder Singh Vs Apollo Munich Health Ins.             CC/19/531

Present:       Sh. S.S. Heer, Advocate for complainant.

                   Sh. Ajay Chawla, Advocate for OPs.

 

                   Arguments heard. Vide separate detailed order of today, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

 

(Monika Bhagat)                             (Sanjeev Batra)

 Member                                  President

 

Announced in Open Commission.

Dated:09.01.2023.

Gobind Ram.