DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, NORTH-WEST,
GOVT. OF NCT OF DELHI
CSC-BLOCK-C, POCKET-C, SHALIMAR BAGH, DELHI-110088.
CC No: 631/2016
D.No._________________________ Dated: _________________
IN THE MATTER OF:
DHARMINDER KUMAR JAIN,
S/o LATE SH. JAGDISH RAI JAIN,
R/o A-3/65, GROUND FLOOR, SEC-11,
ROHINI, DELHI-110085. … COMPLAINANT
Versus
M/s APOLLO MUNICH HEALTH INS. CO. LTD.,
(THROUGH ITS MANAGER),
103, UPPER GROUND FLOOR, ITL TWIN TOWERS,
NETAJI SUBHASH PLACE, RING ROAD,
PITAM PURA, DELHI-110034.
ALSO AT: 2ND& 3RD FLOOR, ILABS CENTRE,
PLOT No. 404, 405, UDYOG VIHAR PH-III,
GURGAON-122016 (HARYANA). … OPPOSITE PARTY
CORAM :SH. M.K. GUPTA, PRESIDENT
SH. BARIQ AHMED, MEMBER
MS. USHA KHANNA, MEMBER
Date of Institution: 11.07.2016
Date of decision: 25.07.2018
SH. M.K. GUPTA, PRESIDENT
ORDER
1. The complainant has filed the present complaint against the OPunder Section 11 & 12 of the Consumer Protection Act, 1986
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therebyalleging that based on the offers, claims and self-boasting representations made, the complainant subscribed for a Mediclaim insurance policy from OP and the policy was subscribed for the medical benefit, security and welfare of the complainant as well as his wife and two sons and after paying the requisiteinsurance premium of Rs.14,631/-, one Mediclaim Insurance Policy no. 110101/11001/1000003940-07 dated 29.04.2015 was issued to the complainant for the period commencing from 29.04.2015 to 28.04.2016 and the sum insured was Rs.3,00,000/- each for the policy holder as well as for his wife and Rs.2,00,000/- each for his two sons. The complainant further alleged that on issuing of the said policy, it was assured to the complainant that the policy encompasses cashless Mediclaim facility for all the insured personsduring any time of requirement and during the validity period and continuing force of the said Mediclaim insurance policy.In October-2015, the complainant having been sick had to undergo diagnose medication and treatment from BLK Super Speciality Hospital, Pusa Road, New Delhi-110005 and had to remain hospitalized from 17.10.2015 to 19.10.2015having been diagnosed Phimosis and was required to incur and bear the medical costs as invoiced by the said hospital. Thereafter, the complainant lodged his claim for re-imbursement of the amount so incurred in medical treatment under
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the medical insurance policy and thereafter an advice was received from OP regarding claim settlement being claim ID no. 350008 cover under UHID no. 10000028196 against the claim amount of Rs.21,479/-, OP settled the amount at Rs.10,814/- and disallowed Rs.8,115/- on false, untenable, sham, bald, vague and imaginary concept. The complainant further alleged that no cogent reason has been assigned by OP as to why the same are non-payable under the policy and likewise vide its settlement letter dated 05.01.2016, OP has wrongly repudiated and not paid the claim of the complainant pertaining to the medical expenses so incurred by the complainant and the complainant made hectic efforts to prevail upon the OP and had been running from pillar to post for payment of the disallowed sum of Rs.10,665/- and OP kept on extending vague and superfluous reasonings and excuses. The complainant further alleged that since OP later stopped attending the complainant and claim was not re-imbursed fully, the complainant then was constrained to serve upon OP a legal demand notice dated 24.02.2016 but OP despite of receipt of the legal notice, did not even bother to send any reply and/or to settle the legitimate claim agitated by the complainant being the amount of Rs.8,115/- disallowed illegally by OP on unsustainable ground. On 22.03.2016, the complainant again sent a reminder to OP asking OP to comply
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with the terms & conditions of the previous demand notice but of no response.
2. On these allegations the complainant has filed the present complaint praying for direction to the OP to pay and re-imburse an amount of Rs.8,115/- alongwith interest @ 18% p.a. as well as compensation of Rs.25,000/- for causing mental, physical pain, agony and harassment alongwith interest @ 20% p.a. till actual payment and has also sought Rs.9,000/- towards cost of litigation.
3. OP has been contesting the complaint and has filed reply. In its reply, OP submitted that the complaint is not maintainable andis liable to be dismissed and there is no deficiencyin service on the part of OP. OP further submitted that the complainant had approached OP’s company for availing insurance policy and as per the process involved the complainant submitted Proposal Form bearing no. 1100035260 dated 26.04.2008 for issuance of an insurance policy namely Easy Health Insurance Policy so as to provide an insurance cover for himself, his wife and two sons. OP further submitted that OP issued a policy bearing no. 110100/11001/1000003940 and policy was further renewed from time to time and the alleged claim is received in policy bearing no. 110100/11001/1000003940-07 to the complainant commencing from 29.04.2008 with policy period from 29.04.2015 to 28.04.2016 based on the statements and representations of the complainant.
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OP further submitted that the complainant submitted the claim Form on 21.12.2015 for re-imbursement of expenses with date of admission 17.10.2015 till 19.10.2015 with final claim amount of Rs.21,479/- and as per the submitted documents, the complainant was admitted with diagnosis of “Phimosis” and the claim was processed and as per the terms & conditions of the insurance policy, the claim with respect to an amount of Rs.10,814/- was settled and admittedly said amount was paid to the complainant. OP further submitted that an amount of Rs.10,665/- was rejected by OP for the following reasons: i) Rs.50/- not payable registration charges, ii) Rs.2,500/- not payable already adjusted in main claim, iii) Rs.1,216/- not payable nor related to main claim, iv) Rs.826/- not payable nor related to main claim, v) Rs.413/- not payable nor related to main claim, vi) Rs.423/- not payable nor related to main claim, vii) Rs.412/- not payable nor related to main claim, viii) Rs.106/- not payable betadine solution, ix) Rs.110/- not payable betadine cream, x) Rs.348/- not payable nor related to main claim, xi) Rs.413/- not payable nor related to main claim, xii) Rs.348/- not payable nor related to main claim & xiii) Rs.3,500/- not payable nor related to main claim. OP further submitted that above said facts and circumstances and for reasons as stated above, the claim of the complainant was only partially allowed and part of the claim was
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rejected which has been done within the purview of the terms & conditions of the policy.
4. Complainant filed rejoinder and denied the submissions of the OPs and further submitted that the OP has taken a misleading plea.
5. In order to prove his case the complainant filed his affidavit in evidence and also filed written arguments. The complainant also placed on record copy of schedule-easy health individual standard issued by OP, copy of bill no. 15-16CA/1170347 dated 13.10.2015 of Rs.50/- towards registration chargesissued by BLK Super Speciality Hospital, Delhi, copies of medical prescriptions dated 08.09.2015, 20.09.2015, 14.10.2015 & 18.11.2015 issued by BLK Super Speciality Hospital, copy of discharge summary showing hospitalization of the complainant in the hospital on 17.10.2015 and discharge on 19.10.2015, copy of claim form, copy of invoice-cum-cash receipt no. 20150909113039 dated 09.09.2015 of Rs.4,210/- & receipt no. 20151016103159 dated 16.10.2015 of Rs.150/- issued by Dr. Lal Path Labs, copy of cash receipt no. 6824 dated 09.09.2015 of Rs.150/- issued by Jain Clinic, copy of advance receipt no. 15-16/406165 dated 13.10.2015 of Rs.2,500/- & receipt no. 15-16CA/1172591 dated 14.10.2015 of Rs.1,000/- issued by BLK Super Speciality Hospital, Delhi, copy of retail invoice/final summary bill dated 19.10.2015 of Rs.31,486/-, copies of provisional bills dated 19.10.2015 of Rs.36,378/-, copy of
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registration slip dated 08.12.2015 issued by North Delhi Pathology Clinic, copy of receipt detailed dated 08.12.2015 of Rs.3,500/- issued by North Delhi Pathology Clinic, copies of receipt no. 718 dated 08.09.2015 of Rs.800/- for consultation, receipt no. 757 dated 29.10.2015 of Rs.500/-, receipt no. 751 dated 20.10.2015 of Rs.500/- & receipt no. 754 dated 24.11.2015 of Rs.500/- for dressing issued by Surgical Clinic, copies of retail invoice no.15014 dated 24.10.2015 of Rs.1,146/- & retail invoice no. 15037 dated 29.10.2015 of Rs.826/- issued by S.S. Medicos, Rohini, Delhi, copies of receipt no. 5505 dated 21.09.2015 of Rs. 348/-, receipt no. 5590 dated 15.10.2015 of Rs.412.90, receipt no. 5595 dated 16.10.2015 of Rs.412.90, receipt no. 5604 dated 19.10.2015 of Rs.1,283.16 & receipt no. 5618 dated 23.10.2015 of Rs.576.05 issued by Shri Radhey Medicos, Delhi, copy of bill/cash no. 2145 dated 03.12.2015 of Rs.2,265.95 issued by Chopra Medicos, copy of retail invoice no. 00417 dated 08.12.2015 of Rs.348/- issued by Sharma Medicos, copy of claim form, copy of settlement letter dated 05.01.2016 issued by OP through e-mail and copies of legal notice dated 24.02.2016 & 22.03.2016 issued by the complainant to OP through speed post alongwith postal receipts.
6. On the other hand, Ms. Deepti Rustagi, Attorney & Authorized Signatory ofOP filed his affidavit in evidence. OP also filed written arguments.
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7. This forum has considered the case of the complainant as well as OP in the light of evidence and documents placed on record by the complainant. The documents and evidence of the parties shows that the complainantwas admitted in BLK Super Speciality Hospital, Pusa Road, New Delhi on 17.10.2015 and was discharged from the hospital on 19.10.2015 for the treatment of “Phimosis”. The earlier medical prescriptions and pathological examinations reports do not support of the OP and it cannot be said that the complainant was suffering from pre-existing disease and there is no justification for the OP to disallow/reject the claim of Rs.8,115/- of the complainant and we are of opinion that OP has wrongfully rejected the claim of the complainant and amounting to Rs.8,115/- and no justified reason has been given by the OP in refusing the said claim amount of the complainant. Thus, OP is held guilty of deficiency in service.
8. Thus, holding guilty for the same, we direct the OP as under:
-
ii) To pay to the complainant an amount of Rs.6,000/- as compensation for harassment and mental agony suffered which includes cost of litigation.
9. The above amount shall be paid by the OPto the complainant within 30 days from the date of receiving copy of this order failing which OP
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shall be liable to pay interest on the entire awarded amount @ 10% per annum from the date of receiving copy of this order till the dateof payment. If OPfails to comply with the order within 30 days from the date of receiving copy of this order, the complainant may approach this Forum u/s 25 of the Consumer Protection Act, 1986.
10. Let a copy of this order be sent to each party free of cost as per regulation 21 of the Consumer Protection Regulations, 2005. Thereafter file be consigned to record room.
Announced on this 25th day of July, 2018.
BARIQ AHMED USHA KHANNA M.K. GUPTA
(MEMBER) (MEMBER) (PRESIDENT)
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