Delhi

West Delhi

CC/16/107

Vipin Kumar - Complainant(s)

Versus

Apollo Munich Health Insurance - Opp.Party(s)

23 Apr 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (WEST)

 

CASE NO. 107/2016

SH. VIPIN KUMAR

ADD- H.NO. 382, TARA NAGAR,

DUGGAL FARM DWARKA MODE,

New Delhi—110078.                                                         …..Complainant

VERSUS

APOLLO MUNICH HEALTH INSURANCE CO. LTD.

612 A, MAHATTA TOWER 54, B-BLOCK,

COMMUNITY CENTRE, JANAKPURI,

NEW DELHI-110058.

TEL: 011-45595353, 45528787                                          …..Opposite Party-1

 

APOLLO MUNICH HEALTH INSURANCE CO. LTD.

10^TH FLOOR TOWER B BUILDING NO. 10,

DLF CITY PHASE 2^ND GURGAON, HARYANA.                …..Opposite Party-2

 

MAHINDRU HOSPITAL

E-1, KIRAN GARDEN, MAIN NAJAFGARH ROAD,

OPP. METRO PILLAR NO. 712, UTTAM NAGAR,

NEW DELHI-110059.                                                        …..Opposite Party-3

 

O R D E R

K.S. MOHI, PRESIDENT

The complainant has filed the present complaint against the OPs under section 12 of the Consumer Protection Act, 1986. Briefly the facts are that complainant had taken a Family Floater Health Policy from OP on 04.12.2014 covering his wife and son. It is further averred that his wife was admitted in Mahindru Hospital from 08.09.2015 to 10.09.2015 due to vomiting/dengu fever. Complainant applied for cashless claim but was rejected by OP stating that there was no need for admission and illness was curable in OPD. However, the patient at the time of admission was suffering from fever, vomiting, stomach ache and was unable to walk.  She was got admitted in the Hospital on the recommendation of the Doctors of the Hospital. After discharge from the Hospital the complainant applied for medi-claim for a sum of Rs. 13,338/- which was rejected by OP by stating that disease was curable in OPD. Hence, the present case.

          After notice OP-1 & OP-2 filed written statement admitting that policy in question was medi-claim was issued to the complainant. Complainant had filed proposal form and declaration form stating that no information is with held nor any statement was false. The complainant after receiving treatment from Mahindru Hospital filed claim in October, 2015 and after receiving the documents, the complainant was directed to supply copy of indoor papers including admission notes and original payment receipts. The OP received documents on 26.10.2015 and after receiving all the medical papers noted that all the vitals and parameters were within the lower limits and no high grade fever noted. Therefore, the claim was rejected on 09.11.2015 by holding that the admission of the patient for investigation and evaluation of ailment only and there was absolutely no need of hospitalization.

          OP-3 also filed written statement admitting that the treatment given to the complainant as per standard medical practice and there is no grievance against OP-3 and has no role in entertaining or repudiating the claim by the insurance companies and prayed for deleted the name from the array of the parties in the present case.

The complainant has filed his affidavit of evidence testifying all the facts as alleged in the complaint and relied upon Ex. CW1/1—Ex. CW1/8.  OP-1 & OP-2 Sh. Deepti Rastogi, Vice-President and Sh. R. Ashwin Kumar, Assistant Manager has filed their affidavit of evidence testifying all the facts as alleged in the written statements and relied upon Ex-OP1/A-OP1/K. On the other hand, OP-3 Dr. Sanjay Mahindru S/o Sh. C.L. Mahindru has also filed affidavit of evidence testifying all the facts as alleged in the written statement and relied upon Ex. R3/1.  Parties have also filed their written submissions.

          We have heard Ld. Counsel for the parties and perused the documents and gone through the material on record carefully and thoroughly.

          During the final arguments on 02.04.2019 Ld. Counsel for OP-1&OP-2, Mr. R.P. Pawar in all fairness, admitted that OP is ready to reimburse medical expenses borne by the complainant for his treatment which is to the tune of Rs. 13,338/-. The counsel for complainant accepted this gesture but submitted that he should be reasonably compensated for harassment and litigation expenses.

          We have perused the file. The complainant in this case was instituted in the year 2016. Though OP-1 & OP-2 contested the complaint by denying the claim on the grounds mentioned in the written statement but after lapse of three years good sense prevailed and OP made statement for settlement. We feel that complainant should be compensated for harassment and litigation expenses.

          Keeping in view the discussion stated above, we award a sum of Rs. 13,338/- to be paid by OP-1 & OP-2. Complainant is further awarded compensation in the sum of Rs. 10,000/- towards harassment and litigation expenses to be paid within 45 days from the receipt of the order. In case of default of payment in time OPs shall be liable to pay interest @ 6% p.a. from the date of filing of the complaint till actual realization.

File be consigned to Record Room.

          Copy of Order be given as per rules.

          Announced this ____23TH_______April, 2019.

 

(K.S. MOHI)                                                                             (PUNEET LAMBA)

PRESIDENT                                                                                     MEMBER