Delhi

East Delhi

CC/427/2015

DEEPAK - Complainant(s)

Versus

APOLLO MUNICH - Opp.Party(s)

26 Sep 2018

ORDER

                     DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, EAST, Govt of NCT of Delhi

                        CONVENIENT SHOPPING CENTRE, 1^st FLOOR, SAINI ENCLAVE, DELHI 110092

  

                                                                                           Consumer complaint no.        427/2015

                                                                                           Date of Institution                11/06/2015

                                                                                           Order reserved on                26/09/2018        

                                                                                           Date of Order                        03/10/2018                                                                                  

In matter of                                                                                                              

Mr. Deepak Kumar Mittal, adult                                                                      

s/o- Sh. Rajendra Prasad Mittal

R/o- B-8, Askoka Niketan,   

Opp. Vigyan Vihar, Delhi 110092 …..……….……………...…………….Complainant

                             

                                      Vs

 

The Managing Director,

Apollo Munich Health insurance Co. Ltd.

Block 17, nr V3S Mall,  

Vikas Marg, Delhi……………………… ...................………....…………..Opponent

 

Quorum        Sh Sukhdev  Singh       President

                       Dr P N Tiwari                Member

                       Mrs Harpreet Kaur      Member                                                                                             

 

Order by Dr P N Tiwari,  Member

Brief Facts of the case  

                                                                                            

Complainant had individual mediclaim policy from New India Assurance Co. from 23/06/2006 for sum insured 2 lacs till 22/08/2011(Ex CW1/Anne.C2 colly). Thereafter, it was stated that complainant opted present mediclaim policy from OP/Apollo Munich Health insurance Co. for sum insured to 4 lacs which was renewed up to 22/08/2015 vide policy no. 110101/11051/1000229829/03 (ex CW1/Anne.C1). It was stated that present OP had waived off certain policy conditions as 6B, 6C and 6D (Ex CW1/Anne.C3) with CB Rs 1,40,000/-given. 

It was stated that complainant was admitted at Sir Ganga Ram Hospital, New Delhi on 24/11/2014 and underwent kidney Transplantation on 26/11/2014 and was discharged on 06/12/2014. The kidney was donated by his father, Mr Rajendra Prasad Mittal. As cashless was denied, so complainant paid hospital bill of Rs 6,77,630/- on 12/12/2014 and then filed claim with OP vide claim (Ex CW1/Anne.C4) which was after repeated clarifications from OP, claim was not settled by the OP. Despite of repeated follow up with OP, but did not receive any satisfactory reply, so sent a legal notice to OP on 13/04/2015 for re imbursement of treatment bill with 18% interest within 7 days (Ex CW1/Anne. C8&9).

When no reply was received, filed this complaint and claimed Rs 5,40,000/- with 18% interest and compensation of Rs one lacs and litigation charges Rs 35,000/-.

OP denied all the facts and alleged allegations stated in the complaint in their written statement though it was admitted that the said policy was issued by OP for a sum insured Rs 4 lacs after complainant opted present OP policy from New India Assurance Co. It was also stated that OP followed all the required formalities for issuing policy after filling policy proposal form by the complainant, but after scrutiny of all the treatment papers taken from Ganga Ram Hospital and letter from the treating doctor, it was seen that complainant was suffering from Diabetes and Hypertension 3-4 years and was on MHD at the time of admission in the hospital on 24/11/2014 (Ex OPW1/3).

It was also admitted that pre authorization letter was received for Rs 6 lacs, but form was incompletely filled so even repeated query, complainant did not submit all the required treatment documents for Hypertension and CKD where he was on regular MHD (Ex OPW/R1A to R1C). When OP did not receive required documents up to 25/03/2015 ‘Closure Letter’ was issued which showed that mandatory documents were pending since long and complainant failed to submit (Ex OPW1/3). Hence, the claim was closed as No claim status. Claim was put under No claim category so OP was not liable to for any deficiency in their services.

OP also took reference of Supreme Court judgment “Satwant Kaur Sandhu vs New india Assurance Co. Ltd. (2009) 8 SCC 316 which laid down that policy is issued on good faith and policy seeker has to disclose all the material facts in the policy proposal form. Here in this case no disclosure of kidney ailment due to Hypertension was done nor was Diabetes disclosed.  OP also submitted references of few judgments where repudiation was justified for non disclosure of material facts in policy proposal form as under-

1. Seemax Constructions Pvt Ltd vs SBI, AIR 1992,Delhi 197.
2. SP Chengalvarya Naidu vs Jagannath, AIR 1994 SC 853
3. Bam Dev vs United India insurance Co. Ltd. I (1994)CPJ 425.
4. PC Chacko & others vs Chairman LIC, CA 5322/2007, SC
5. New India Assurance Co. Ltd. vs Pradeep Kumar, I (1997) CPJ 94 Delhi.

Hence, no claim was justified by OP based on the law laid down in above judgments. So, complaint may be dismissed. 

Complainant submitted his rejoinder and denied all the replies submitted by OP in their written statement. He relied on all the facts of his complaint as true and correct. He submitted evidences through his own affidavit and stated on oath that all his evidences were correct which were submitted with complaint as policy documents, terms and conditions, and claim form. Complainant had also submitted certain references of judgments where it was laid down that OP had to submit evidence of pre existing ailment prior to the inception of policy under these citations as-

a)- NIAC Ltd vs Murari Lal Bhusri, NC 2011(3) CPJ 198.

b)- NIAC vs Bimla Devi Jhunjhunwala, NC 2011(4).

c)- Sushil Kumar Jain vs UIIAC, NC 2012(1)

d)- Dr T Suresh vs OIC, AIR 86 AP.

e)- Biman Krishna Bose vs UIIAC, 2001 (6)ScC 477.

 

Complainant also submitted few more references of State Commissions where repudiation was not justified by OP. He stated that OP had mentioned wrong facts in their ‘Closure Letter’ as claimant had timely submitted all the required documents to OP.

OP submitted evidences on affidavit through Md. Deepti  Rustagi,  VP Legal with OP who reaffirmed on oath that their Closure of Claim was justified on the basis of non submission of required treatment documents and non disclosure of material facts “Hypertension and Diabetes with MHD in CKD”. It was necessary to disclose all the relevant information pertaining to personal health in proposal form which was a vital document for OP and not disclosing by complainant pertains hiding material facts. It was well accepted fact that OP issued policy based on good faith and all the information disclosed by the policy seeker was mandatory. Here complainant had not submitted required documents for claim process despite of repeated intimations. Hence, closure of claim was justified by OP based on policy terms and condition. OP also stated that all evidences were on record and supported by their affidavit. 

OP and complainant had also filed their written arguments and taken on record.

Arguments were heard from both the party counsels. After perusal of file and evidences on record, order was reserved.

After perusal of all the documents on record including terms and conditions of the policy, it is clear that  complainant has not submitted required treatment documents as asked by OP. Complainant had also not submitted hospital bills and discharge summary. This means that complainant had no knowledge of claim process.

Considering incomplete cause of action and seeing no deficiency in the services and process of OP, it is now complainant to comply and submit all the claim documents to OP for completing claim process. He is directed to comply the claim submission process in 30 days from the receiving of this order and thereafter OP shall process the claim in further 60 days under Policy terms and conditions. There shall be no order to any cost.  

Copy of this order be sent to the parties as per the Section 18 (6) of the Consumer Protection Regulation, 2005 (in short the CPR) and file be consigned to Record Room under Section 20(1) of the CPR.

 

(Dr) P N Tiwari  Member                                                                         Mrs  Harpreet Kaur  Member                                                                                                                         

                                      

                                                  Shri  Sukhdev Singh  President