DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, NORTH-WEST,
GOVT. OF NCT OF DELHI
CSC-BLOCK-C, POCKET-C, SHALIMAR BAGH, DELHI-110088.
CC No: 804/2016
D.No._________________________ Dated: _________________
IN THE MATTER OF:
Smt. BALWANT KAUR,
W/o LATE SH. S. PRATAP SINGH,
R/o BLK. G-20/259-260,
3RD FLOOR, SECTOR-7,
ROHINI, NEW DELHI-110085. … COMPLAINANT
Versus
APOLLO MUNICH HEALTH INS. CO. LTD.,
THROUGH ITS BRANCH MANAGER,
BRANCH OFFICE: 103, UPPER FLOOR,
RAMPURA MARG, PITAMPURA,
NEW DELHI-110034.
ALSO AT: CORPORATE OFFICE
(THROUGH ITS MD/DIRECTOR/AR)
AT 10TH FLOOR, TOWER-B, BUILDING NO. 10,
DLF CYBER CITY, DLF CITY PHASE-II,
GURUGRAM, HARYANA-122002. … OPPOSITE PARTY
CORAM: SH. M.K. GUPTA, PRESIDENT
SH. BARIQ AHMED, MEMBER
MS. USHA KHANNA, MEMBER
Date of Institution: 11.08.2016
Date of decision: 07.02.2020
SH. M.K. GUPTA, PRESIDENT
ORDER
1. The complainant has filed the present complaint against OP under Section 12 of the Consumer Protection Act, 1986 thereby alleging
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that the complainant purchased a medical insurance policy no. 110100/11001/1000135087 dated 27.11.2010 from OP’s agent in 2010 and as per the advise of the agent she was examined by authorized doctor of OP and was found medically fit for the above said policy. The complainant further alleged that at the time of examination, the complainant apprised and showed the previous medical record to the agent and the doctor who had apprised the complainant and her son that the insurance policy will be issued to the complainant only on the basis of the reports of the investigations which were being done at that time and accordingly the loading charges were added in the premium of the policy of the complainant which were duly paid by the complainant. Thereafter, the complainant renewed her policy and paid the premium alongwith loading charges for the years 2011-2012, 2012-2013, 2013-2014, 2014-2015 & 2015-2016. On 11.01.2016, the complainant had complaints of vomiting, headache and giddiness and was admitted to emergency department, Max Super Speciality Hospital, Shalimar Bagh, Delhi and a cashless request was raised by the hospital on 11.01.2016 and that was rejected due to non-availability of the documents by OP and OP company has sought some documents and discharge summary of 2009 from the hospital (7 years old medical documents of the complainant) to which the son of the complainant replied and the desired documents were not available and a declaration with regards to the same was made on
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12.01.2016 by the son of the complainant and despite the declaration made by the son of the complainant cashless claim was rejected by OP and the son of the complainant was asked to seek reimbursement only. The complainant was discharged from the hospital on 13.01.2016 and had to pay a sum of Rs.54,598/- from her pocket despite having an insurance cover from OP. On 23.01.2016, the son of the complainant has submitted the claim form alongwith the documents with OP-1 and on 18.02.2016, the claim of the complainant was repudiated through letter, citing the reasons for repudiation as non-disclosure of previous medical illness and the attending Doctor of the complainant clearly certified that the present illness (for which the claim has been claimed) has nothing to do with her previous illness which was treated and the patient has fully recovered from that disease. Thereafter, despite several reminders and requests made by the son of the complainant through mails, the claim of the complainant was repudiated by OP. The complainant further alleged that complainant has very well renewed her insurance policy with OP on 15.11.2015 as was scheduled and had paid the premium with loading charges and to the utter shock and disbelief of the complainant and her son, the complainant received a letter dated 13.02.2016 thereby arbitrarily cancelling the policy of the complainant vide cancellation endorsement no. 1000135087-05/3/22/2016 stating that the policy of the complainant was cancelled for non-disclosure of
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material facts without giving an appropriate chance to the complainant to put forward her stand. The complainant further alleged that the complainant had purchased the health policy for herself after the assurances from the agent of OP and had disclosed all material facts to the agent and the doctor regarding the previous medical record of the complainant and the complainant made a claim after five and half years of continuous insurance with OP and the complainant paid extra loading charges with the premium to OP since the inception of the policy with OP and the complainant is fully covered under the terms and conditions of the policy and is feeling cheated at the hands of OP and the repudiation of the claim and the cancellation of the policy of the complainant is illegal and unlawful conduct of OP. The complainant further alleged that the complainant sent legal notice dated 06.06.2016 through her Counsel to OP but of no use.
2. On these allegations the complainant has filed the present complaint praying for direction to OP to pay Rs.54,598/- i.e. amount/bill of the hospital deposited by the son of the complainant as well as compensation of Rs.1,00,000/- for causing mental agony, physical and harassment and the complainant also sought Rs.33,000/- as cost of litigation. The complainant also sought to direct OP to withdraw the letter dated 22.03.2016 of cancellation of the policy of the complainant for the year-2015-2016.
3. OP has been contesting the complaint and has filed reply wherein
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OP submitted that the complaint is not maintainable and is liable to be dismissed and there is no deficiency in service on the part of OP. OP further submitted that the complainant has a medical history of thalamic bleed in 2009 which CT head finding in 2009, Venticular Hemorrhage and subdural Hemorrhage in temporal reason and renal calculus and cholelithiasis since 2009 and the fact was deliberately concealed in the proposal form based on which the insurance policy was issued to the complainant. OP further submitted that OP has rightly repudiated the claim of the complainant u/s VII (j) of the General Conditions of the policy and cancelled the policy due to non-disclosure and concealment of the facts u/s VII (s)(ii) of the General Conditions of the policy.
4. The complainant filed replication and denied the submissions of the OP and further submitted that the OP has taken a misleading plea.
5. In order to prove her case, the complainant filed her affidavit in evidence and also filed written arguments. The complainant also placed on record copy of cover note dated 27.11.2010 issued by OP, copy of proposal form, copy of check list prepared by the executive of OP, copy of cheque bearing no. 234488 dated 09.11.2010 of Rs.7,831/- drawn on Corporation Bank in favour of OP, copy of thanks letter dated 19.11.2010 sent by OP to the complainant, copy of customer information sheet-standard plan issued by OP, copy of letter dated 22.11.2011 sent by OP to the complainant regarding renewal of health insurance coverage, copy of schedule-easy health
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individual standard policy issued by OP for the policy period from 25.11.2011 to 24.11.2012 (mid-night), copies of letters dated 14.11.2012, 22.11.2013, 04.11.2014 & 15.11.2015 sent by OP to the complainant regarding renewal of easy health insurance policy sent by OP to the complainant, copies of Schedule-Easy Health Individual Standard for the period from 25.11.2012 to 24.11.2013 (mid-night), 25.11.2013 to 24.11.2014 (mid-night), 25.11.2014 to 24.11.2015 (mid-night) & 25.11.2015 to 24.11.2016 (mid-night) issued by OP, copies of letters dated 11.01.2016 & 12.01.2016 sent by OP to the Max Super Speciality Hospital, copy of letter dated nil sent by the son of the complainant to OP regarding non-availability of discharge summary, copies of investigation report issued by MGS Hospital, copy of Urine examination report, copy of chest X-Ray report, copy of discharge summary alongwith various test reports, copy of Inpatient Bill (detailed) dated 13.01.2016 of Rs.54,598.89 issued by Max Super Speciality Hospital, Shalimar Bagh, Delhi and copies of receipts of Rs.30,000/- & Rs.24.598.89 deposited by the complainant with OP, copies of rejection letters dated 12.01.2016 and 18.02.2016, copy of certificate dated 12.01.2016 issued by concerned doctor of Max Super Speciality Hospital, Shalimar Bagh, Delhi that the patient Ms. Balwant Kaur is admitted for accelerated hypertension with Encephalopathy and she had Thalamic Biced in 2009 but the same is not related to her previous illness which was treated and patient was fully recovered from that disease and copy
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of legal notices dated 02.07.2016 alongwith courier receipt sent by the complainant through her Counsel to OP as well as proof of delivery report.
6. On the other hand, Ms. Deepti Rustogi, constituted Attorney of OP filed her affidavit in evidence. OP also filed copy of proposal form, copy of medical examination report, copy of schedule-easy health individual standard, copies of additional information request form dated 11.01.2016, copies of CT report dated 03.01.2009 and 06.01.2009, copy of denial of cashless service dated 12.01.2016, copy of claim form and copy of repudiation letter dated 02.02.2016. OP also filed written arguments.
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 complainant was admitted in Max Super Speciality Hospital, Shalimar Bagh, Delhi on 11.01.2016 and was discharged from the hospital on 13.01.2016 for the treatment of Accelerated Hypertension with BPPV and LT Renal Calculus with past history “as nothing significant” and after treatment was discharged from the hospital on 13.01.2016. The doctor of the hospital vide certificate dated 12.01.2016 has clearly stated that the patient Ms. Balwant Kaur is admitted for accelerated hypertension with Encephalopathy and she had Thalamic Biced in 2009 but the same is not related to her previous illness which was treated and patient
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was fully recovered from that disease. On the other hand, OP has not been successful in proving its defence that the claim was rejected on the ground of concealment of previous illness. Moreover, the policy to the complainant was issued by OP after her medical check-up and various examinations by the duly authorized doctor of OP. Thus, we are of opinion that the complainant has not concealed the fact of previous illness and furthermore the said illness was not connected or in any manner concerned with the disease for the treatment of which the complainant was hospitalized on 11.01.2016. Furthermore in the present claim the complainant is seeking refund of medical expenses of the period prior to the cancellation of the policy and it seems that there is no genuineness in the defence of OP. Refusal by the OP to pay to the complainant the hospitalization expenses including medicine bills, test fees and consultancy fees of the doctors and subsequently cancelling the policy amounts to deficiency in service. Thus, OP is held guilty of deficiency in service.
8. Thus, holding guilty for the same, we direct OP as under:
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ii) To pay to the complainant an amount of Rs.40,000/- as compensation for causing harassment and mental agony.
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iii) To pay to the complainant an amount of Rs.10,000/- towards cost of litigation.
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9. The above order shall be complied by OP and amount shall be paid by OP to the complainant within 30 days from the date of receiving copy of this order failing which OP 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 date of payment. If OP fails 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 25/27 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 7th day of February, 2020.
BARIQ AHMED USHA KHANNA M.K. GUPTA
(MEMBER) (MEMBER) (PRESIDENT)
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UPLOADED BY: SATYENDRA JEET
