BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.410 of 2015
Date of Instt. 18.09.2015
Date of Decision: 11.07.2017
Mohinder Pal Singh aged about 62 years Son of Balwant Singh, House No.556, Greater Kailash, Near CT Public School, Jalandhar. Mobile No.9815904950.
..........Complainant Versus
Appolo Munich Health Insurance, 1st Floor, Satnam Complex, New Court Road, Near Yes Bank, BMC Chowk, GT Road, Jalandhar-144001, through its Branch Manager.
….… Opposite party
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh, (President),
Sh.Parminder Sharma (Member)
Present: Sh. SC Sood, Adv. Counsel for the complainant.
Sh. VK Gupta, Adv. Counsel for the OP.
Order
Karnail Singh (President)
1. This complaint filed by the complainant, wherein alleged that the complainant has taken a medical policy No.180200/11001/AA00200066. The complainant has been availing medical insurance since year 2008 from various insurance companies. That earlier the petitioner was insured with United India Insurance Company Limited for the period 27.02.2015 to 26.02.2016. The OP approached the complainant for medical insurance policy being provided by the OP. It was also assured and promised that the policy would be cashless policy i.e. money would be instantly and directly paid to the hospital and the complainant shall not be required to pay any money for hospitalization. The complainant believing assurance of OP, paid the premium in total Rs.23,027.79/- and after being satisfied about the conditions of the policy, the OP issued policy for one year and the complainant was insured for total sum of Rs.5,00,000/-. The policy was posted by disclosing fully about the earlier medical policies of the complainant for last so many years with United India Insurance Company without any lapse or break. The same is also recognized by the terms and conditions of the OP.
2. The calculation of the premium was also done by keeping in view earlier insurance availed by the complainant and as such complainant was to be medically insured for the period of one year from 27.02.2015 till 26.02.2016. That during the subsistence of the policy, the complainant suffered from ailment and he was admitted to Patel Hospital, Jalandhar and as assured by OP, the complainant approached the OP for payment of the hospital amount to the hospital, which is in total comes to Rs.32,910/-. The OP showed helplessness and did not pay the said amount in spite of the policy being cashless and complainant was eventually discharged on 14.06.2015. The claim regarding the medical policy was lodged on 11.06.2015. That the complainant submitted all the documents on medical treatment along with relevant bills to the OP after discharge on 18.06.2015 and a letter was also written, but the OP did not show any response.
3. That the complainant subsequently again got admitted on 09.07.2015 on account of calculus of kidney. The said claim has also remained unpaid and the claim of Rs.60,611/- was lodged. The complainant's claim has been wrongly rejected. The complainant also sent a notice on 22.06.2015. The OP rejected the claim by stating therein that the illness which has a specific two year of waiting period as per the policy. The policy start date was taken by the OP from 27.02.2015 and only due to this contention, the claim was rejected. The complainant thereafter even submitted document and also explained when this policy was taken it was pointed out to the OP that the petitioner has been taking policy since 2008 and the OP was also fully aware that earlier the petitioner has been taking the policy from United India Insurance Company Limited and knowingfully well the earlier insurance, the fresh insurance was issued by the OP. The contention of the OP as per rejection is totally unwarranted, illegal, void, wrong and OP has wrongly taken the stand and has wrongly repudiated the claim. The OP has not paid any amount to the petitioner. That the OP has adopted undue trade practice and has taken undue advantage. That there is a deficiency on the part of the OP as the OP failed to discharge the services efficiently, as such the OP is liable to pay the said amount. The complainant has further entitled to the damages of Rs.50,000/- on account of deficiency in service and further Rs.10,000/- is to be paid on account of costs incurred on the present litigation. The complainant is also entitled to interest @ 15% per annum from the date of commencement of the medical treatment as the OP has wrongly refused the payment of the claim on flimsy grounds and lastly prayed that the complaint of the complainant may be accepted and OP be directed to pay an amount of claim Rs.93,521/- and damages to the tune of Rs.50,000/- and litigation expenses of Rs.10,000/- alongwith interest 15% per annum.
4. Notice of the complaint was given to the opposite party and accordingly opposite party appeared through his counsel and filed written reply and contested the complaint by taking preliminary objections that a prima facie no cause of action has arisen in favour of the complainant to file the present complaint, as ailment for which claim facility was claimed falls under the Waiting Period clause of the policy. Hence, no benefit may be given to the complainant in terms of the policy as demanded by him and further alleged that the complainant has raised two reimbursement claims with the OP. That for the first reimbursement claim for the date of admission 11.06.2015 and date of discharge 14.06.2015 for an amount of Rs.32,019/-. Further another claim was raised for the date of admission as 09.07.2015 and date of discharge 10.07.2015 for an amount of Rs.60,613/-. That both of the claims were due to illness and treatments related to Calculus diseases of Urogenital system which will be covered subject to waiting period as specifically mentioned in the policy schedule of the complainant hence the rejection of both the claim is as per the terms and conditions of the policy and there is no deficiency in service or negligence or unfair trade practice and further alleged that the complainant is not entitled to any relief in equity, since the complainant has not approached this Forum with clean hands and is guilty of concealing material facts. That in the Proposal Form and also during the Medical Examination Form, the complainant has not mentioned any past medical history however in the present medical documents submitted by the complainant himself it is revealed that the complainant has a past surgical history of renal stone 6 year back and this clearly amounts to a non-disclosure on the part of the complainant himself and with prejudice to the present claim in hand, the company is at liberty to terminate the policy of the complainant. The complainant has not only concealed the material facts but also concocted false story to wrongfully gain from the answering OP company. Further it is submitted that despite receipt of the policy wording the complainant has not placed on record full policy wording and only a single page is attached with the complaint which establishes the malafide intention of the complainant and the answering OP stand of repudiation of the claim. On merits, the purchase of the policy from OP by the complainant is admitted but other all allegations are categorically denied and lastly submitted that the complaint of the complainant is without merit and same may be dismissed.
5. In order to prove the claim of the complainant, counsel for the complainant tendered into evidence affidavit of the complainant Ex.CW-1/A and some documents Ex.C1 to Ex.C16 and closed the evidence on behalf of the complainant.
6. Similarly, counsel for opposite party tendered into evidence affidavit Ex.OPA alongwith some documents i.e. Power of Attorney Ex.OP-1, Proposal Form Ex.OP-2, Portability Form alongwith policy of United India Insurance Ex.OP-3, Insurance Policy alongwith terms and conditions (consisting of 24 pages) Ex.OP-4, Pre-authorization Form alongwith documents (consisting of 6 pages) Ex.OP-5, Claim Form alongwith documents including Rejection Letter dated 03.07.2015 Ex.OP-6, Claim Form alongwith documents and Rejection Letter dated 03.08.2015 Ex.OP-7 and closed the evidence.
7. We have heard the learned counsel for the respective parties and also gone through the case file very minutely.
8. It is admitted case of the party that the complainant has purchased insurance policy from OP and copy of the same has been placed on the file by the complainant as Ex.C-1 and terms and conditions Ex.C-2 and two letters were sent by the complainant to the OP for making the payment of the claim and these letters are Ex.C-3 and Ex.C-4 and previous insurance policy of United India Insurance Company of the complainant is Ex.C-5 and repudiation letter Ex.C-6. Apart from that the complainant has also produced on the file, bills Ex.C7 and Ex.C14/A for an amounting to Rs.32,019/- and Rs.56,873/- respectively and second Claim Form Ex.C15 and Legal Notice Ex.C16 and entire case of the complainant is based upon these documents and claiming the treatment amount from the complainant alongwith interest and compensation.
9. To the contrary the plea of the OP is only two fold, first of all the OP took a ground for rejection of the claim that the complainant has intentionally and willfully concealed the material facts i.e. previous ailment which is very much clear from the documents, submitted by the complainant himself which shows that the complainant has past surgical history of renal stone 6 year back and due to that reason the complainant is not entitled for the claim because he intentionally concealed the material facts from the insurance policy i.e. OP in regard to previous ailment.
10. But we want to make it clear here that the aforesaid plea has been taken by the OP first time in the written statement and claim of the complainant is not rejected on the basis of the concealment of previous ailment rather the claim of the complainant has been simply rejected on the basis of terms and conditions as elaborated in Section VI (A) (II) and as per this Section 2 year of waiting period is required as per policy and as such the claimant is not entitled for the claim regarding that the repudiation letter is Ex.C6. Apart from that the OP has also brought on the file to prove the said Section VI (A) (II) by placing on the file Proposal Form Ex.OP-2, Portability Form along with policy of United India Insurance Ex.OP-3, Insurance Policy along with terms and conditions Ex.OP-4. With the insurance policy Ex.OP4, the terms and conditions are also attached and main stress of the OP is on the term and condition which is categorically incorporated at Page No.6.
11. We have gone through the entire documents as well as pleading and find that the claim of the complainant is rejected only on the basis of Section 6 (A) (II), but if we take into consideration the said Section 6 (A) (II), then we can say without any hesitation that the policy has been obtained by the complainant for one year i.e. from 27.02.2015 to 26.02.2016 and two year period will not come during the subsistence of that policy, obtained by the complainant, if so then, what will be useful for the complainant to get the policy. So, this term and condition itself proved to be vague and not legal and not binding upon the complainant because signature of the complainant was obtained on the policy Ex.OP-2 and Portability Form Ex.OP-3 but the schedule and insurance policy alongwith term and condition has not been signed by the complainant at any time, if so then, how this Section 6 (A) (II) came to the notice of the complainant, if so then, the complainant is not bound by this term and condition rather the said term and condition is self imposed by the OP.
12. No doubt the counsel for the OP has also referred the above said two years waiting period in the insurance policy in Heading No.8 “General Exclusion” but we have gone through the said “General Exclusion” and find that the disease of the complainant is not mentioned to be covered under the two year waiting period. So this General Exclusion is not itself self explanatory and does not disclose whether in what type of cases this exclusion clause is applicable. So, from the over all circumstances, it has become clear that the claim of the complainant is wrongly and illegally rejected by the OP without any reason and rhyme. Therefore, repudiation letter Ex.C-6 is set aside and further hold that the complainant is entitled for claim as demanded by way of two Claim Form Ex.C-13 and Ex.C-15.
13. In the light of above detailed discussion, the complaint of the complainant is partly accepted and OP is directed to pay the claim amounting to Rs.93,251/- to the complainant along with interest @ 9% per annum from the date of repudiation of the claim i.e. 08.07.2015 till realization and further OP is directed to pay a compensation of Rs.10,000/- to the complainant for mental harassment and also directed to pay litigation expenses of Rs.3000/-. The entire compliance be made within one month from the date of receipt of the copy of order. Complaint could not be decided within stipulated time frame due to rush of work.
14. 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 Parminder Sharma Karnail Singh
11.07.2017 Member President
