Delhi

East Delhi

CC/657/2015

ANIL - Complainant(s)

Versus

APOLLO MUNICH - Opp.Party(s)

24 Jul 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. 657/15

 

Shri Anil Kumar

R.o 678, West Guru Angad Nagar

Laxmi Nagar, Delhi – 110 092                                   ….Complainant

 

Vs.    

 

1. M/s. Apollo Munich Health Ins. Co. Ltd.

Through its Branch Manager/Officer In-charge/AR

204, Laxmi Deep Building

Laxmi Nagar Distt. Centre

Delhi – 110 092

 

Also at:

415, Som Dutt Chamber-II

Bhikaji Kama Place, New Delhi-66

 

2. M/s. Apollo Munich Health Ins. Co. Ltd.

Through its M.D./AR

Plot No. 404 & 405, 2^nd & 3^rd Floor

ILABS Centre, Udyog Vihar Phase-III

Gurgaon – 1221 016, Haryana                                         …Opponents

 

Date of Institution: 26.08.2015

Judgement Reserved on: 26.07.2018

Judgement Passed on: 27.07.2018

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 Anil Kumar against              M/s. Apollo Munich Health Insurance Co. Ltd., Laxmi Nagar (OP-1) and M/s. Apollo Munich Health Insurance Co. Ltd., Gurgaon (OP-2) under Section 12 of the Consumer Protection Act, 1986 with allegations of unfair trade practice and deficiency in service. 

2.         The facts in brief are that complainant Anil Kumar got insurance policy number 110106/11051/AA00031108 issued on 08.02.2014, valid upto 24.00 hrs. 07.02.2015 at the instance of Shri Sanjay Malhotra, agent of M/s. Apollo Munich Health Insurance Co. Ltd. (OP).  Mr. Sanjay Malhotra got this policy issued by showing “in-patient treatment covers hospitalization expenses for a period more than 24 hours”.  An amount of Rs. 4,586.65/- was paid for the policy which was for the complainant and his wife. 

            It is stated that during the cover of the policy, complainant got ill health with severe stomach intolerable pain with vomiting and body pain and got himself checked from Aarogya Hospital where the doctors advised him to be admitted on 12.11.2014.  He got himself admitted by showing his cashless card and policy.  This was informed to M/s. Apollo Munich Health Insurance Co. Ltd. (OP).  They sent an authorization letter in respect of cashless treatment of the complainant on 13.11.2014 vide PA No. 152226/1 to the hospital. 

            On 17.11.2014, when the complainant was to be discharged, the hospital showed him another letter of dated 17.11.2014 where cashless service was denied.  The reason mentioned in the denial letter was “Cashless facility cannot be granted as presenting ailment for which treatment is sought comes under two years exclusion list of policy terms and conditions” which was never disclosed to the complainant, neither by the agent nor the respondent company.  The complainant being helpless paid an amount of Rs. 38,208/- which was arranged by him having a casual loan. 

            The complainant submitted his claim to M/s. Apollo Munich Health Insurance Co. Ltd. (OP) through Shri Sanjay Malhotra, agent, which was again declined with the same remarks. 

            Legal notice was given to OPs.  Thus, it has been stated that denial of claim of the complainant amounts to deficiency in service for which he has suffered mental pain and agony.  Hence, he has claimed an amount of Rs. 38,208/- and compensation of Rs. 10,00,000/- on account of suffering  and cost of proceedings.

3.         In reply, M/s. Apollo Munich Health Insurance Co. Ltd. (OP) have taken various pleas stating that complainant have failed to submit the mandatory documents as required for processing the claim.  It has been stated that in the absence of receipt of required documents, his claim was closed. 

            They have further stated that the treatment taken for the disease was excluded under the Exclusion Clause.  Hence, the complainant was to wait for a period of two years. 

            They have also stated that it was found from the discharge summary that the treatment taken was for “Acid Peptic disorder + RUT positive” which falls under waiting period of two years.  That being so, the cashless facility was withdrawn.  They have denied other pleas.

4.         Rejoinder to the WS of OP was filed by the complainant where the contents of the WS have been denied and has reaffirmed the averments of his complaint.   

5.         In support of its case, the complainant have examined himself.  He has deposed on affidavit.  He has narrated the facts which have been stated in the complaint. 

            In defence, M/s. Apollo Munich Health Insurance Co. Ltd. (OP) have examined Ms. Deepti Rustagi who has also deposed on affidavit.  She has also narrated the facts which have been stated in the WS.  She has got exhibited documents such as copy of proposal form and policy schedule and terms and conditions (Ex.R-1), copy of medical literature (Ex.R-1a), cashless application received from Aarogya Hospital (Ex.R-2), copy of approval letter for Rs. 10,000/- (Ex.R-3), copy of discharge summary  (Ex.R-4), copy of letter dated 17.11.2014 (Ex.R-5), copy of Authorization Letter (Ex.R-5a), copy of claim form (Ex.R-6), copy of letter dated 31.12.2014 (Ex.R-7) and copy of letter dated 07.02.2015 (Ex.R-8). 

5.         We have perused the written arguments and material placed on record as none of the parties appeared to argue.  The plea taken by       M/s. Apollo Munich Health Insurance Co. Ltd. (OP) in the written arguments filed has been that the claim for the illness which the complainant was having, has a specific two years of waiting period as per the policy terms and conditions, due to which the claim was repudiated.  This is the only argument which has been taken on behalf of M/s. Apollo Munich Health Insurance Co. Ltd. (OP). 

            Whether this plea was sustainable, a look has to be made to the testimony of the complainant as well as Deepti Rustagi, AR of OP.  In the testimony of the complainant, he has stated that he got himself admitted in Aarogya Hospital on 12.11.2014 and was discharged on 17.11.2014.  The discharge summary of the hospital which has been placed on record shows that the complainant was treated for “Acid Peptic disorder + RUT positive”.  The policy was issued on 08.02.2014 which was valid till 07.02.2015.  Thus, the fact remains that the treatment was taken by the complainant during the subsistence of the policy.  The treatment taken by the complainant was for “Acid Peptic disorder + RUT positive” which was given in the discharge summary. 

            In the testimony of Deepti Rustagi, AR of OP, it has been stated that the treatment taken by the complainant for “Acid Peptic disorder + RUT positive” falls under gastrointestinal treatments and surgeries under Ulcer and Erosion of stomach and duodenum.  “Acid Peptic disorder + RUT positive” disease has been explained as “Excessive  secretion of acid and pepsin is responsible for damage to the delicate mucosa and lining of the stomach, esophagus and duodenum resulting in ulceration” which leads to gastric/duodenal ulcer and GERD for which the period of two years was the waiting period. 

            Thus,  from the testimony of Deepti Rustagi, AR of OP, coupled with the discharge summary and the terms and conditions of the policy and the Exclusion Clause, it is evident that the treatment taken by the complainant falls under gastrointestinal category for which there was a waiting period of two years.  The complainant have taken the treatment during the subsistence of the policy which was not covered.  That being so, the repudiation of claim by M/s. Apollo Munich Health Insurance Co. Ltd. (OP) was justified.  Therefore, there was no deficiency on the part of OP. 

            When there was no deficiency on the part of M/s. Apollo Munich Health Insurance Co. Ltd. (OP), the complaint of the complainant deserves its dismissal and the same is dismissed.  There is no order as to cost.    

            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