Complaint No: 212 of 2019.
Date of Institution: 26.06.2019.
Date of order: 11.09.2023
Bhupinder Singh S/o Harbans Singh R/o Shivam Colony, Opposite Taragarh Morh, Dinanagar, Tehsil and District Gurdaspur.
.....Complainant.
VERSUS
- Apollo Munich, SCO-4, 3rd Floor, District Shopping Centre, Ranjit Avenue, Amritsar, through its Manager.
- Apollo Munich, Corporate office, 1st Floor, SCF 19, Sector 14, Gurgaon, Haryana – 122001, through its Manager.
….Opposite parties.
Complaint u/s 12 of the Consumer Protection Act, 1986.
Present: For the Complainant: Sh.Sandeep Ohri, Advocate.
For the Opposite Parties: Sh.Sachin Mahajan, Advocate.
Quorum: Sh.Lalit Mohan Dogra President, Sh.Bhagwan Singh Matharu, Member.
ORDER
Lalit Mohan Dogra, President
Bhupinder Singh, Complainant (here-in-after referred to as complainant) has filed this complaint under section 12 of the Consumer Protection Act, (here-in-after referred to as 'Act') against Apollo Munich Etc. (here-in-after referred to as 'opposite parties).
2. Briefly stated, the case of the complainant is that the complainant got the health policy from the opposite parties firstly on 26.5.2014 and after that continuously getting the policy from the opposite parties every year. The last policy is from 27.5.2018 to 26.5.2019. The policy holder name Bhupinder Singh complainant and the group policy No. is 120100/12001/2018/A012708/004. It is further pleaded that the above facts clearly show that the complainant is insured with the opposite parties for the last more than 4 years as such the complainant falls within the definition of consumer as provided under the consumer protection act 1986. It is further pleaded that during the period of the policy the complainant fell ill as he felt heaviness in chest and complainant went to the Chohan Multispecialty hospital Pathankot for treatment and was admitted on 28.10.2018 and discharged on 1.11.2018. It is further pleaded that patient was treated with ACS pharmacotherapy and the amount of Rs.1,70,700/- as hospital bill has been paid to the Chohan Multispecialty and Trauma Center Hospital. It is further pleaded that bill of medicines was Rs.10,566/- and has been duly paid by the complainant. It is further pleaded that the intimation has been duly given to the opposite parties immediately at the time of admitting in the hospital and after discharge all the requisite formalities has been duly completed and the claim form alongwith the other documents has been duly sent to the insurance company for reimbursement. It is further pleaded that the insurance company sent letter dated 30.1.2019 to the complainant and in the said letter demanded the further documents. It was further alleged that the matter of fact is that all the documents has already been provided to the insurance company and even attached with the present complaint also, but inspite of all this the insurance company repudiated the claim of the complainant illegally vide letter dated 7.2.2019. It is further pleaded that the letter sent by the opposite parties is illegal and there is no non compliance on the part of the complainant and all the bills and the treatment record have already been sent to the insurance company but they are making false excuses. It is further pleaded that due to this illegal act and conduct of the opposite parties the complainant has suffered great loss and also suffered mental agony, Physical harassment and inconvenience as such there is a clear cut deficiency in service on the part of the opposite parties.
On this backdrop of facts, the complainant has alleged deficiency and negligence in service and unfair trade practice on the part of the opposite parties and prayed that necessary directions may kindly be issued to the opposite parties to pay the claim of Rs.1,81,266/- i.e. Rs.1,70,700/- plus Rs.10,566/- and the opposite parties may also be directed to pay the compensation of Rs.50,000/- for deficiency in services and mental pain, agony and harassment and Rs.20,000/- as litigation expenses to the complainant, in the interest of justice.
3. Upon notice, the opposite parties appeared through counsel and contested the complaint and filing their written reply by taking the preliminary objections that the complaint is not maintainable and is liable to dismissed as no cause of action ever arose in favor of the Complainant and against the Opposite Parties No.1 & 2 to file the present complaint and hence, the complaint under reply is an abuse of the process of law and as such the same is liable to be dismissed. It is further pleaded that the instant complaint is false, malicious, incorrect and malafide and is nothing but an abuse of the process of law and it is an attempt to waste the precious time of this Hon’ble Commission as the same is filed by the complainant only to avail undue advantage and the complaint is thus liable to be dismissed under Section 26 of the Consumer Protection Act, 1986 (here-in-after referred to as the ‘Act’, that without prejudice to above objection, the opposite parties submits at the outset the above complaint filed by the complainant is not at all maintainable either on question of fact or on question of law and as such is liable to be dismissed in limine. It is further pleaded that before providing reply to the allegations and contentions of the complainant as contained in the said Complaint, the O.P’s hereby raise a preliminary question as to the maintainability of the instant case interalia on the following grounds:
- The instant complaint is not maintainable in its present form in facts and/or in law and/or as per the provisions of the Consumer Protection Act, 1986 (as amended till date).
- The Complainant has no cause of action for filing the instant case against the O.P’s.
- The instant case and prayer is barred by law of limitation, acquiescence, estoppels.
- The instant case is harassing and speculative in nature and as such is an abuse of the process of law.
- The Complainant has suppressed the material facts and/or submitted distorted facts to mislead this Learned Commission which will be apparent and substantiated from the evidence of the OP’s hereinafter.
- This Ld. Commission has no jurisdiction to try the instant complaint.
- The complainant has filed this complaint which is frivolous, bad in law and frustrating and vexatious, malafide in nature with ulterior motive to cause damage and harassment to the OP’s.
- There shall be defeat of justice and equity if the prayer of the Complainant is granted.
- This complaint suffers from non-joinder and mis-joinder of necessary parties.
- The complaint is nothing but a gross abuse of the process of this Ld. Commission.
- The instant complaint filed is totally misconceived.
- Because of the above mentioned reasons as such the instant complaint may be dismissed with exemplary costs.
It is further pleaded that the complaint is barred by the section 3 of the Consumer Protection Act, 1986 and the same is liable to be relegated to the civil court of competent jurisdiction, that the opposite parties submit that claims are paid by any Insurance company out of the common pool of funds belonging to all policyholders of the company and Insurance company has to check the admissibility of a claim before honoring it as such any payment as claimed in the complaint would be an undue discrimination with the other policy holders who are insured in same risk pool with identical health condition in which complainant claimed herself to be vide her Proposal Form. It is further pleaded that the complainant had intentionally and with malafide intention suppressed the material facts of his wife's previous illness from the opposite parties and for which the complainant is not entitle to get any kind of relief and compensation. It is further pleaded that the present complaint is liable to be dismissed as the complainant has got the policy issued by mis-representation of the material facts, which was material for the opposite parties company. It is further pleaded that the complainant was admitted in 2013 for Subdural hematoma before policy inception which was concealed from the opposite parties at the time of taking policy, that in the light of above, the Complainant is not at all entitled to any benefit under the Policy and the present complaint is liable to dismissed as the complainant has concealed the material fact about his previous disease and treatment thereof. It is pleaded that the Complainant had signed and submitted the Application/Proposal Form bearing No. CB00045779 and the date of the application form was 25.05.2014. It is further pleaded that the Opposite Parties under reply had issued an Easy Health Group Insurance Policy to Canara Bank wherein Canara Bank was the master policy holder and who would enroll Canara Bank customers under the ambit of the Easy Health Group Insurance Policy and all the members enrolled in the policy would be subject to the terms and conditions of the Easy Health Group Insurance Policy. It is further pleaded that subsequently complainant was enrolled in the Easy Health Group Insurance Policy in 2014. It is further pleaded that Complainant signifying that he has been enroled as part of Easy Health Group Insurance Policy as per the terms and conditions thereof. It is submitted that the Policy Kit containing all relevant documents were duly sent and admittedly received by the complainant. It is further submitted that the Policy Kit containing all relevant documents were duly sent and delivered to the Complainant/proposer at various lime, thereby giving an opportunity to Complainant to verify and examine the benefits, terms and conditions of the Policy taken by the Complainant. It is pertinent to submit that the complainant/proposer never approached the Opposite parties stating that any information given in the documents in the Policy Kit was incorrect or any term and condition therein was not acceptable to him from the receipt of the policy document to review the terms and contract of the policy. It is further pleaded that opposite parties have strictly issued the policy based on information disclosed by the Proposer and as such the said complaint is liable to be dismissed on this ground alone. It is further pleaded that the complainant had lodged the claim with OP’s on 10.12.2018 for reimbursement with Date of Admission 28.10.2018 and Date of Discharge 01.11.2018 wherein patient was admitted for diagnosis of HYPERTENSION, DM, OPERATED FOR ICH - 5 YEARS BACK, CORRONARY ARTERY DISEASE, ACUTE IWMI WITH RVMI WITH SHOCK WITH CHB, PRIMARY VT DC CARDIOVERTED 3, TPI FB CAG-SVD, PRIMARY PTCA RCA DONE with final claimed amount Rs.1,81,266/-. It is further pleaded that the opposite parties had reviewed the submitted documents and as per discharge summary it noted that complainant had operated for ICH 5 years back so get clarity Opposite parties has raised query vide letter dated 09.01.2019 for submission of required documents which was necessary to process the claim and also sent reminders vide letter dated 19.01.2019, 30.01.2019 but Complainant had not submitted the required document with company so finally OP’s company rejected the claim of complainant vide letter dated 07.02.2019. It is further pleaded that after rejection of claim, Complainant had submitted a Certificate of K.D. Hospital stating that "Complainant was admitted on dated 30.09.2013 under Regd No.1646/13 under Diagnose B/L chronic subdural hematoma and Patient underwent surgical intervention on dated 02.11.2013 and discharge on 06.10.2013.” It is further pleaded that it was clear that complainant had past history of subdural Hematoma and he was operated for the same in 2013 which was not disclosed with OP’s company at time of taking policy and complainant had taken policy with OP’s company in 2014. Hence the claim of the complainant was rejected vide letter dated 23.04.2019.
On merits, the opposite parties have reiterated their stand as taken in legal objections and denied all the averments of the complaint and there is no deficiency in services on the part of the opposite parties. In the end, the opposite parties prayed for dismissal of complaint with costs.
4. Learned counsel for the complainant has tendered into evidence affidavit of Bhupinder Singh (Complainant) as Ex.C-1/A along with other documents as Ex.C-1 to Ex.C-14.
5. Learned counsel for the opposite parties has tendered into evidence affidavit of Ms. Deepti Rustagi, (Senior Vice President of Opposite Parties Company, M/s Apollo Munich Health Insurance Co. Ltd.) as Ex.OP-1 along with other documents as Ex.OP-2 to Ex.OP-7.
6. Rejoinder filed by the complainant.
7. Written arguments filed by the complainant but not filed by the opposite parties.
8. Counsel for the complainant has argued that the complainant got the health policy from the opposite parties for the first time on 26.5.2014 and after that is continuously getting the policy and the last policy is from 27.5.2018 to 26.5.2019. The policy holder name Bhupinder Singh complainant fell ill as he felt heaviness in chest and complainant went to the Chohan Multispecialty hospital Pathankot for treatment and was admitted on 28.10.2018 and discharged on 1.11.2018. It is further argued that patient was treated with ACS pharmacotherapy and the amount of Rs.1,70,700/- as hospital bill has been paid to the Chohan Multispecialty and bill of medicines was Rs.10,566/-. It is further argued that on intimation the insurance company sent letter dated 30.1.2019 to the complainant and in the said letter demanded the further documents. It was further argued that the matter of fact is that all the documents has already been provided to the insurance company but inspite of all this the insurance company repudiated the claim of the complainant illegally vide letter dated 7.2.2019 which is clear cut deficiency in service on the part of the opposite parties.
9. Ld counsel for the opposite parties has argued that the complainant had intentionally suppressed the material facts of his wife's previous illness from the opposite parties and for which the complainant is not entitled to get any kind of relief and compensation. It is further argued that the complainant was admitted in 2013 for Subdural hematoma before policy inception which was concealed from the opposite parties at the time of taking policy, as such Complainant is not at all entitled to any benefit under the Policy and the present complaint is liable to dismissed as the complainant has concealed the material fact about his previous disease and treatment thereof. It is plea that the complainant had lodged the claim with OP’s on 10.12.2018 for reimbursement with Date of Admission 28.10.2018 and Date of Discharge 01.11.2018 and as per discharge summary Ex C2 HYPERTENSION, DM, OPERATED FOR ICH - 5 YEARS BACK, CORRONARY ARTERY DISEASE, ACUTE IWMI WITH RVMI WITH SHOCK WITH CHB, PRIMARY VT DC CARDIOVERTED 3, TPI FB CAG-SVD, PRIMARY PTCA RCA DONE and the final claimed amount is Rs.1,81,266/-. It is further plea of the opposite party that after rejection of claim, Complainant had submitted a Certificate of K.D. Hospital stating that "Complainant was admitted on dated 30.09.2013 under Diagnose B/L chronic subdural hematoma and Patient underwent surgical intervention on dated 02.11.2013 and discharged on 06.10.2013 and it was clear that complainant had past history of subdural Hematoma and was operated upon for the same in 2013 which was not disclosed with OP’s company at time of taking policy and complainant had taken policy with OP’s company in 2014 as such the claim of the complainant was rejected vide letter dated 23.04.2019 and as such the complainant should be dismissed being abuse of the process of the law.
10. We have heard the counsel for the parties and gone through the record. It is admitted fact that complainant had purchased health policy from the opposite parties which commenced on 26.05.2014 which is evident from copy of policy of insurance Ex.C1 and valid upto 26.05.2019 on being renewed from time to time. It is further admitted fact that complainant remained admitted in Chohan Multispecialty hospital Pathankot w.e.f. 28.10.2018 to 01.11.2018 which is evident from discharge summary Ex.C2. It is further not denied by the opposite parties that complainant had spent amount of Rs.1,81,266/- on his treatment with the said hospital. It is further admitted fact that claim was lodged by the complainant with the opposite parties and the claimed lodged by the complainant has been repudiated by the opposite parties vide letter Ex.C14 on the ground of non disclosure of pre-existing disease.
11. To prove his case complainant had placed on record discharge summary Ex.C2 as per which in the column of final diagnose HYPERTENSION, DM, OPERATED FOR ICH - 5 YEARS BACK, CORRONARY ARTERY DISEASE, ACUTE IWMI WITH RVMI WITH SHOCK WITH CHB, PRIMARY VT DC CARDIOVERTED 3, TPI FB CAG-SVD, PRIMARY PTCA RCA DONE is mentioned, whereas form the pleadings of the opposite parties and evidence it has come on record that in the year 2013 complainant was operated upon for subdural hematoma. The dictionary meaning of subdural hematoma is a collection of blood between brain and outer most recovery and reasons for subdural hematoma are primarily due to head injury. Meaning thereby that subdural hematoma for which the complainant was operated upon has no connection with the disease in respect of which complainant took treatment as per discharge summary Ex.C2. Moreover, the only plea of opposite parties is regarding concealment of pre-existing disease but we are of the view that in some time of life or the other time in life time a person may suffer from some disease or the other with which the disease in dispute has no connection cannot be made ground for repudiation of the medical claim.
12. We have also placed reliance upon the judgment of Hon'ble Supreme Court of India in case titled as Om Parkash Ahuja Vs. Reliance General Insurance Co. Ltd. etc. reported in Law Herald (SC) 2023(2) Page 1560 wherein in it has held as under
"Insurance Health Insurance Complainant had taken health insurance for his family which was renewed time to time His wife suffered from cancer of ovary and took treatment Claim for reimbursement of medical expenses was repudiated on the ground that wife of complainant was suffering from heart disease and it was not disclosed at the initial time of taking policy Medical Certificate establishes that rheumatic heart disease and carcinoma ovary are not related to each other Thus, non-mentioning of disease from which the wife of appellant suffered at the time of purchasing the policy was not material, as the death was cause from a different disease all together Both had no relation with each other Insurance Company directed to pay the claim amount with interest".
In the said judgment the Hon'ble Supreme Court of India has very categorically held that rheumatic heart disease and carcinoma ovary are not related to each other and as such repudiation of the claim by insurance company was held to be illegal.
13. From the evidence on record and by relying upon the judgment of Hon'ble Supreme Court of India we come to the conclusion repudiation of claim by the opposite parties on the ground of pre-existing disease is not justified and the repudiation of the claim of the complainant amounts to deficiency in service.
14. Accordingly, the present complaint is partly allowed and opposite parties are directed to pay Rs.1,81,266/- to the complainant alongwith interest @ 9% P.A. from the date of filing of the complaint till realization. Opposite parties are further directed to pay Rs.10,000/- as damages for mental tension, harassment and cost of litigation. Entire exercise will be completed within 30 days from the date of receipt of copy of this order.
15. The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.
16. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record room.
(Lalit Mohan Dogra)
President
Announced: (B.S.Matharu)
Sept, 11, 2023 Member
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