DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, GURGAON-122001.
Consumer Complaint No: 399 of 2013. Date of Institution: 29.11.2013 Date of Decision: 18.09.2015
Ashish Khurana s/o Sh. Anil Khurana, Flat No.3063 A-Block, Tower No.4, Plot No.GH-7,Crossing Republic NH-24, Dundahera, Ghaziabad (UP).
……Complainant.
Versus
The Manager, Apolo Munich Health Insurance Company Ltd, 10th Floor Building No.10, Tower-B, DLF Cyber City, Gurgaon
Also at
C/o IInd & IIIrd Floor, Ilabas Centre, Plot No.404-405, Udyog Vihar, Phase-III, Gurgaon, Haryana.
..Opposite party
Complaint under Sections 12 & 14 of Consumer Protection Act,1986
BEFORE: SH.SUBHASH GOYAL, PRESIDENT.
SMT JYOTI SIWACH, MEMBER
SH.SURENDER SINGH BALYAN, MEMBER.
Present: Sh. Sanjay Kumar, Adv with Sh. Ashish Khurana, complainant in person.
Ms.Charu Sachdeva , Adv for the opposite party.
ORDER SUBHASH GOYAL, PRESIDENT.
The case of the complainant, in brief, is that he obtained Optima Restore Insurance Coverage vide Policy No.110102/11122/6000027289 for his family which was valid from 10th April, 2012. However, during the subsistence of the insurance policy Jaanvi daughter of complainant was admitted in Moolchand Medcity, New Delhi on 03.07.2013 and was discharged on 06.07.2013 and on account of said treatment the complainant paid a sum of Rs.48,020/-. The complainant submitted the bills to the opposite party for reimbursement of the claim but the claim of the complainant was repudiated on the ground that in view of clause 4.3 of the policy the claim was not maintainable and as such the same tantamounts to deficiency in service. He prayed that the opposite party be directed to pay Rs.60,000/- with interest @ 24 % p.a. The complaint is supported with an affidavit and the documents placed on file.
2 OP in its written reply has alleged that the claim of the complainant has rightly been repudiated by the opposite party in terms of clause 4 (C ) of the insurance policy as the treatment was given for acute pharyngitis which fall in the category of ENT and the treatment of ENT has been excluded for two years whereas the aforesaid illness has taken place within one year of the policy. Thus, the claim of the complainant has been rightly repudiated and there was no deficiency in service on the part of the opposite party.
3 We have heard the learned counsel for the parties and have perused the record available on file carefully.
4 Therefore, from the facts and circumstances of the case, evidence on the file and the arguments advanced by the learned counsel for the parties, it emerges that the complainant has filed the present complaint against the OP alleging deficiency of service on their part on the ground that he obtained Optima Restore Insurance Coverage vide Policy No.110102/11122/6000027289 for his family which was valid from 10th April, 2012 to 09.04.2014. However, during the subsistence of the insurance policy Jaanvi daughter of complainant was admitted in Moolchand Medcity, New Delhi on 03.07.2013 and was discharged on 06.07.2013 and on account of said treatment the complainant paid a sum of Rs.48,020/-. The complainant submitted the bill to the opposite party for reimbursement of the claim but the claim was repudiated on the ground that in view of clause 4(C ) of the policy the claim was not maintainable and as such the same tantamounts to deficiency in service on the part of the opposite party in view of law laid down in case M/s Life Insurance Corporation of India and Others Vs Devinder Sharma 1986-2002 Consumer 6744 (NS) and Oriental Insurance Co. Ltd Vs V.K.Sharma and Ano I(2003) CPJ 584.
5 However, as per the contention of the opposite party the claim has rightly been repudiated in terms of Clause 4(C )of the policy as the treatment was given for acute pharyngitis which fall in the category of ENT and the treatment of ENT has been excluded for two years whereas the aforesaid illness has taken place within one year of the policy. To substantiate his arguments learned counsel for the opposite party has placed reliance on United India Insurance Co. Ltd Vs M/s Harchand Rai Chandan Lal decided on 20.09.2004 in Appeal (Civil) 6277 of 2004 (SC), R.W.H.Ghyaz Ahmed V New India Assurance Co. Ltd I(2013) CPJ 23 (NC), National Insurance Co. Ltd Vs Arun Kumar Goyal 1(2011) CPJ 266 (NC), Bajaj Allianz General Insurance Co. Ltd Vs R.Venkatesh I (2015) CPJ 512 (NC) and Payal Garg Vs Oriental Insurance Co. Ltd I (2015) CPJ 733 (NC).
6 Therefore, after going through the facts and circumstances of the case and the medical record on file it emerges that patient Jaanvi was admitted in Moolchand Medcity, New Delhi on 03.07.2013 on account of fever, headache and vomiting which later on diagnosed as acute pharyngitis. It is pertinent to mention here that in the Exclusion Clause 4 (C) of the policy none of the treatment as mentioned in the said clause was administered to the patient who was treated for fever, acute and vomiting which may be due to infection from virus, PM, Pollens and allergy which is very common in India. No surgical intervention of whatever kind was done by the concerned hospital, therefore, in our view Exclusion Clause 4 (C ) is not applicable in the facts and circumstances of the case and as such we hold that non reimbursement of the amount under the policy tantamounts to deficiency in service on the part of the opposite party. However, the authorities relied upon by the learned counsel for the opposite party are not applicable to the facts and circumstances of the case.
7 Therefore, we direct the opposite party-insurance company to reimburse the amount of Rs.48,010/- as shown in the Bill No.13-14CA1487 dated 06.07.2013 with interest @ 9 % p.a. from the date of filing of the complaint i.e. 29.11.2013 till realization. He is also entitled to compensation of Rs.5,000/- for harassment and mental agony. He is also entitled to litigation expenses of Rs.3100/-The opposite party-insurance company shall make compliance of the order within 30 days from the date of receipt of the copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the records after due compliance.
Announced (Subhash Goyal)
18.09.2015 President,
District Consumer Disputes
Redressal Forum, Gurgaon
(Jyoti Siwach) (Surender Singh Balyan)
Member Member
