Delhi

East Delhi

CC/503/2014

POONAM - Complainant(s)

Versus

Apollo Munich Insurance - Opp.Party(s)

01 Feb 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. NO.  503/14

 

Shri Poonam Jain

R/o H. No. 1/6025

Kabul Nagar, Shahdara

Delhi – 110 032                                                           ….Complainant

 

Vs.

 

Apollo Munich Health Insurance Co. Ltd.

10^th Floor, Tower-B, Building No. 10

DLF Cyber City Phase –II

Gurgaon, Haryana – 122 002                                             …Opponent

 

Date of Institution: 31.05.2014

Judgement Reserved on : 01.02.2018

Judgement Passed on: 02.02.2018

 

CORUM:

Sh. Sukhdev Singh (President)

Dr. P.N. Tiwari (Member)

Ms. Harpreet Kaur Charya (Member)

 

Order By: Sh. Sukhdev Singh (President)

 

JUDGEMENT

            This complaint has been filed by Shri Poonam Jain against          M/s. Apollo Munish Health Insurance Co. Ltd. (OP), under Section 12 of the Consumer Protection Act, 1986. 

2.         The facts in brief are that the complainant obtained a Health Shield Insurance Policy in the year 2009 which was renewed from time to time for a sum of Rs. 2,00,000/- for the period from 16.05.2013 to 15.05.2014 on paying a premium of Rs. 13,780/-.  He was issued a computerized policy without any terms and conditions. 

            In the month of November 2013, wife of the complainant had some problem and was admitted on 18.11.2013 in Sant Parmanand Hospital.  She remained there till 19.11.2013 and was discharged with advice to get it checked again.  The complainant gave intimation to the respondent.  He was shocked when he came to know that his cashless facility was rejected.  He again contacted the respondent and was assured that the amount paid will be reimbursed.  After assurance, he made a payment of Rs. 22,832/- to the hospital.  He got the claim registered with respondent which was repudiated vide their letter of dated 20.11.2013. 

            It has been stated that non-settlement of the claim of the respondent for six months was a clear case of deficiency in service on the part of respondent.  Thus, he has claimed an amount of Rs. 22,832/- (though not mentioned in the complaint) with interest @ 24%; Rs. 50,000/- on account of mental pain and suffering and Rs. 15,000/- as litigation charges.     

3.         In reply, respondent have taken various pleas stating therein that wife of the complainant was suffering from Hypothyroidism (20-25 years), Insomnia, Fibroadenosis and Dysfunctional Uterine Bleeding (DUB) at the time of entering into the contract of insurance with the respondent.  Thus, it has been stated that there was mis-representation, non-disclosure and concealment of material facts.  She was having pre-existing diseases at the time of proposal. 

            It has further been stated that at the time of filling the proposal form, the complainant and his wife were explained all the features of the policy by the insurance agent.  They had also given a declaration and warranty about the disclosure made by them while entering into the contract of insurance with the respondent company.   Thus, it has been stated that the complainant was not entitled for any relief. 

            It has also been stated that the cashless authorization letter dated 16.11.2013 for Rs. 14,000/- was denied.  Their final claim for an amount of Rs. 26,963/-, which was submitted by the complainant on 30.11.2013 for reimbursement for the date of admission on 18.11.2013 to 20.11.2013 was repudiated on the ground that Mrs. Pooja Jain (wife of the complainant) was having Insomnia, Fibroadenosis and Dysfunctional Uterine Bleeding (DUB) since 2009 which was not revealed in the proposal form dated 25.04.2011.  Thus, non-disclosure of medical condition which was material from underwriting perspective amounts to suppression of material facts and therefore, in terms of Section VII(r)(ii) of the policy of the complainant was liable to be terminated.  Accordingly, the policy was terminated and claim was declined which was duly communicated to the complainant vide letters of dated 24.01.2014, 25.01.2014 and 24.02.2014.  They have denied other facts also.

4.         The complainant has filed rejoinder to the WS of OP, wherein he has controverted the pleas taken in the WS and reasserted his pleas. 

5.         Evidence by way of affidavit was filed by Shri Poonam Jain, complainant, where he has narrated the facts which have been mentioned in the complaint. 

            In defence, OP have examined Ms. Deepti Rustagi, Vice President-Legal, who have also deposed on affidavit.  She has narrated the facts which have been stated in their written statement.  She has also got exhibited documents such as copy of POA of Ms. Deepti Rustagi (Ex.RW-1/1), copy of proposal form bearing no. 1101027700 dated 23.04.2011 (Ex.RW-1/2), copy of policy schedules (Ex.RW-1/3colly.), copy of cashless authorization requisition form, communications between the hospital and OP company including letter dated 16.11.2013 and cashless denial letter dated 20.11.2013 (Ex.RW-1/4colly.), final claim form and decline letters (Ex.RW-1/5 colly.&1/6), discharge summary of 22.01.2009 and 19.11.2013, issued by Sant Parmanand Hospital (Ex.RW-1/7&1/8) and copy of policy cancellation letter dated 24.02.2014 (Ex.RW-1/9).

6.         We have heard Ld. Counsel for the parties and have perused the material placed on record. The only point which has been raised on behalf of Apollo Munich Health Insurance Co. Ltd. (OP) has been that the complainant has concealed material facts about the prior medical history of Mrs. Pooja Jain as she was suffering from Hypothyroidism (20-25 years), Insomnia, Fibroadenosis and Dysfunctional Uterine Bleeding (DUB) at the time of entering the contract of insurance with the respondent company.

            On the other hand, Ld. Counsel for the complainant have argued that there was no concealment of facts.

            To appreciate the arguments of Ld. Counsel for the parties, a look has to be made to the testimony of the complainant as well as testimony of Ms. Deepti Rustagi and the material got exhibited in their testimony.  Firstly, the proposal form has to be looked into.  If a look is made to the proposal form (Ex.RW1/2), it is noticed that under the column ‘Medical & Life Style Information’, which is in respect of medical history, all the columns under Section ‘A’ with regard to the diseases suffering from such as Hypertension, Chest Pain, Ischemic heart diseases etc. etc., the word ‘N’ has been mentioned.  Similarly, under Section ‘B’, the word ‘N’ has been repeated.  This proposal form has been of dated 23.04.2011. 

            Under Column 10 of the form, a declaration has been made saying that all the statements made, were true and complete in all respects and there was no other information which was relevant to the said application.  Though, the complainant have stated in his proposal form that Pooja Jain, his wife was not suffering from any disease, now, it has to be seen from the documents, which has been placed on record as to whether she was having any disease or not prior to filling the proposal form.  For this, the discharge summary of Sant Parmanand Hospital got exhibited as RW1/7 and RW1/8 have to be examined. 

            If a look is made to discharge summary of Sant Parmanand Hospital (Ex.RW1/7), it is noticed that this discharge summary was of the year 2009 when she was admitted in the hospital on 21.01.2009 and discharged on 22.01.2009.  Under the column Medical History, it has been stated that “known case of hpothyroidism x 15 years and history of Fibroadenosis – 10 years back”.  Under the column Diagnosis, it has been stated as “P3L3 with hypothyroidism with DUB, D&C done under GA on 22.01.2009”. 

            Similarly, in the discharge summary (Ex.RW1/8) which is of the year 2013 under the Column Diagnosis “P3L3 with Post Menopausal bleeding PV with diabetes with hypothyroidism.  D&C done under GA on 19.11.2013” and under the column Past History “Hypothyroidism since 20-25 years, Diabetic since 4 months, Insomnia since 2-3 years”. 

            Thus, from these two discharge summaries, it is evident that wife of the complainant was a patient of Hypothyroidism for the last 15 years, fibroadenosis for 10 years and insomnia since 2-3 years. 

            The claim has been rejected on the ground that medical history of complainant’s wife was that she was having insomnia, fibroadenosis and DUB, which were not revealed in the proposal form.  From the evidence on record, it is noticed that the proposal form categorically list the diseases to which the answer has to be given in Yes/No, particularly Anaemia, DUB, fibroid, thyroid disorder etc. etc.  The complainant have answered as ‘No’ to these diseases, though she was suffering from these diseases as is evident from the discharge summary.  When she has given answer in negative to these disorders, she has not disclosed true facts.  Thus, the rejection of the claim by the insurance company on the ground of non-disclosure of material facts was justified.  Therefore, there cannot be said to be any deficiency on the part of insurance company.  When there was no deficiency on the part of OP, no case of the complainant has been made out.  Therefore, his complaint deserves its dismissal and the same is dismissed.    

            Copy of the order be supplied to the parties as per rules.

            File be consigned to Record Room.

 

(DR. P.N. TIWARI)                                              (HARPREET KAUR CHARYA)

Member                                                                                Member    

 

            (SUKHDEV SINGH)

             President