Haryana

Ambala

CC/157/2018

Prem Parkash Uppal - Complainant(s)

Versus

Apollo Munich - Opp.Party(s)

18 Jul 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMBALA.

 

                                                                      Complaint case No.:  157 of 2018.

                                                          Date of Institution         :   17.05.2018.

                                                          Date of decision    :   18.07.2019.

 

Prem Parkash Uppal, s/o Late Shri Ram Lal, r/o 216, Palika Vihar, Ambala City.

……. Complainant.

                                                Versus

 

1. Apollo Munich, 4749-SCOm 4^th Floor, Sector-34A, Mukat Hospital, Dakshin Marg, Chandigarh.
2. Ashish Luthra, Manager, Grievance Management Team, Apollo Munich Health Insurance Co. Ltd., iLABS Centre, IInd & IIIrd Floor, Plot No.404,405, Udyog Vihar, Phase-III, Gurgaon-122 016 (Haryana).
3. Sanjay Pandey, Agent, Apollo Munich Health Insurance Co. Ltd., R/o House No.70, Satsang Vihar, near Ekta Vihar, Ambala Cantt.
4. Yashpal Sehgal s/o Shri Om Parkash, r/o 2781, Hari Palace Road, Ambala City.

     ….…. Opposite Parties.

 

Before:        Smt. Neena Sandhu, President.

                   Smt. Ruby Sharma, Member.

Shri Vinod Kumar Sharma, Member.                 

                            

Present:       Shri Umrao Singh Mahi, Advocate, counsel for complainant.

Shri Rajesh Kumar, Advocate, counsel for the OPs No.1 & 2.

OPs No.3 & 4 ex parte.

 

Order:        Smt. Neena Sandhu, President

Complainant has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to OPs No.1, 2 & 3:-

1. To pay the sum assured amount of Rs.2,00,000/-
2. To pay Rs.50,000/- towards interest on the money borrowed by the complainant for his treatment.
3. To pay Rs.30,000/- as compensation for the mental agony and physical harassment suffered by him.
4. To pay Rs.11,000/- as litigation charges.
   382.  

                   Any other relief which this Hon’ble Forum may deem fit.

 

                   Brief facts of the case are that the complainant purchased a Medical & Health Insurance Policy bearing No.111300/11108/AA00512991 for the period from 26.11.2016 to 25.11.2018 from OP No.1, through OPs No.3 & 4, after paying Rs.25,648.45. During the commencement period of the policy, he suffered from coronary artery disease & unstable angina disease and remained under treatment from 16.04.2017 to 18.04.2017 in Max Superspeciality Hospital, Mohali and spent Rs.3 lacs on his treatment. Since under the policy, he was insured for Rs.2 lacs, therefore, lodged the claim with the OPs for Rs.2 lacs. In the treatment record of Mehra Hospital, the doctor prescribed tablet “Mazetol 200 mg” and the OPs No.1 & 2 treated 200 mg since 2009 and rejected his claim vide letters dated 19.07.2017, 23.05.2017, 30.11.2017 and 05.03.2018. He requested the OPs No.1 & 2 several times to reimburse the cost of treatment upto the value of insurance cover of Rs.2 lacs, but they did not reimburse the same. A registered AD legal notice dated 30.03.2018 was served upon the OPs to make the payment of insurance cover of Rs.2 lacs alongwith compensation of Rs.30,000/-, but all in vain. By not paying the claim amount, the OPs No.1,2 & 3 have committed deficiency in service. Hence, the present complaint.

2.                 Upon notice, the OPs No.1 & 2 appeared and filed written version and raised preliminary objections regarding maintainability; cause of action; jurisdiction; limitation; non-joinder & mis-joinder of necessary parties and concealment of material facts. On merits, it is stated that upon verification, it was noted that the complainant is having history of trigeminal neuralgia since 2009. This fact was not disclosed at the time of inception of the policy, hence, the complainant had violated the terms & conditions of the policy. The complainant approached the OP Company for availing health insurance policy. As per the process involved, the proposer has given his consent for issuance of policy after understanding terms & conditions as mentioned in the proposer form Easy Health Individual Standard Insurance Policy. Believing the above said information and details provided by the proposer including the medical history, to be true, correct and complete in all respect, giving due credence to the under writing norms of OP, a policy was issued to the proposer. On 16.04.2017, a cashless request was received from Max Superspeciality Hospital, Mohali with the date of admission 16.04.2017 for C/o chest pain diagnosis made CAD, with estimated amount of Rs.15000/-. Post scrutiny of the documents, H/o Hypertension was noted and query was made and the case was marked for investigation. On investigation, it was found that the complainant is having history of trigeminal neuralgia since 2009. There was non-discloser of trigeminal neuralgia (ailment) which may have an impact on the policy, hence the request for cashless facility was rejected. After rejection of cashless request, claim was received for reimbursement of amount Rs.2 lacs, incurred on the treatment of Coronary Artery Disease, unstable angina, but to get more clarity, queries were made to the insured, which are as under:-

1. Kindly provide exact duration of for trigeminal neuralgia and hypertension with first prescription when diagnosed. 
2. Your case has been sent for verification by proceeding team, request your cooperation during visit of our verifier. We will revert with the decision on the case post verification report is submitted.

                   The Ops received the reply form, from the insured and he denied any past history both for hypertension and trigeminal neuralgia. Meanwhile, Dr. Mehra’s certificate was received, in which, he stated that trigeminal history was since 2009. From this certificate, it is clear that the complainant had a past medical history of trigeminal neuralgia since 2009 and same was not disclosed by him in the Proposal Form. Hence, the claim is repudiated due to non disclosure and concealment of facts under Section VII (j) of the policy terms & conditions and also the policy has been cancelled. Rest of the allegations levelled by the complainant were denied for lack of knowledge and prayer has been made for dismissal of the present complaint.

                   Upon notice, initially OP No.3 appeared through counsel, but on 16.11.2018, when the case was fixed for fixed for filing written version, the learned counsel appearing on behalf of OP No.3 had made a statement that he has no instruction to appear on behalf of OP No.3. However, on that date, none had appeared on behalf of OP No.3, as such, he was proceeded against ex parte vide order dated 16.11.2018 by this Forum.

                   Upon notice, none has turned up on behalf of OP No.4, accordingly he was proceeded against ex parte.

3.                The ld. counsel for the complainant tendered affidavit of the complainant as Annexure CA alongwith documents as Annexure C-1 to C-12 and closed the evidence on behalf of complainant. On the other hand, learned counsel for OPs No.1 & 2 tendered affidavit of Deepti Rustagi, constituted Attorney of M/s Apollo Munich Health Insurance Co. Ltd., Hyderabad as Annexure OP1/A alongwith documents Annexure OP1 to OP2, Annexure C1 to C12 and closed the evidence on behalf of OPs No.1 & 2.

4.                We have heard the learned counsel of the parties and carefully gone through the case file and also the written argument filed by the learned counsel for the OPs No.1 & 2 and the case laws referred by the ld. counsel for the complainant.

5.                At the outset, the learned counsel for the OPs No.1 & 2 has raised the objection that the insurance company is not having its office at Ambala and the policy in question has been issued by the Karnal office, therefore, this Hon’ble Forum has no jurisdiction to adjudicate the matter involved in the present complaint. To this effect, the leaned counsel for the complainant has argued that OPs No.3 & 4 are the agents of insurance company i.e. OPs No.1 & 2 and are doing the business for and on behalf of the insurance company at Ambala and the complainant being resident of Ambala, had taken the policy in question from Ops No.3 & 4 at Ambala. Therefore, the objection raised by the learned counsel for the OPs No.1 & 2 that this Forum has no territorial jurisdiction to adjudicate the matter in question, is not tenable. In the proposal form (Annexure C-1) under the Column No.7 AGENT’S DECLARATION, name of Mr. Yashpal Sehgal i.e. OP No.4 has been mentioned. Even in the policy document Annexure OP/1, in the column “Intermediary Name”, Mr. Yashpal has been mentioned. From the head-note of the complaint, it is evident that Mr. Yashpal is resident of Ambala City. This plea of the complainant that OP No.4 is the resident of Ambala and being the agent of insurance company i.e. Ops No.1 & 2, is doing business at Ambala, has not been controverted by the Ops No.1 & 2. In this view of the matter, we have no hitch to say that OP No.4 is the agent of insurance company i.e. OPs No.1 & 2 and the complainant had taken the policy in question at Ambala, therefore, as per Section 11 of the CP Act, this Forum has territorial jurisdiction to adjudicate upon the matter involved in the present complaint. Hence, this objection raised by learned counsel for the OPs No.1 & 2, is not tenable, hence rejected.

6.                 On merits, the learned counsel for the complainant has argued that during the subsistence of the policy in question, complainant had taken treatment from Max Superspeciality Hospital, Mohali for coronary artery disease & unstable angina and had spent Rs.3 lacs. The complainant was insured under the policy for a sum assured of Rs.2 lacs. Accordingly, he lodged the claim with the OPs No.1 & 2, for reimbursement of amount of Rs.2 lacs. However, the OPs No.1 & 2 repudiated his genuine claim vide letter dated 19.06.2017 on the ground that complainant was suffering from trigeminal neuralgia since 2009, but he did not disclose the said fact at the time of taking the policy in question. The Ops No.1 & 2 have wrongly alleged that the complainant was not suffering from the trigeminal neuralgia since 2009, as nowhere in the certificate dated 30.05.2017 (Annexure C-8) or in the prescription slip dated 13.04.2017 (Annexure C-10) issued by Mehra Hospital, it has been mentioned that complainant was suffering from trigeminal neuralgia since 2009. From the said documents, it is clear that the doctor had prescribed Mazetol 200 mg and by misrepresenting it as year 2009, the Ops No.1 & 2 have wrongly repudiated the claim. To support of his contention, the ld. counsel for the complainant has placed reliance on the cases, titled as New India Assurance Company Ltd. Vs. B.Y. Srikanta, IV (2015) CPJ, 380 (NC); State Health and Allied Insurance Co. Ltd. Vs. Ravi Bansal & Anr., First Appeal No.458 of 2017, date of decision 21.12.2017 (SC) and Manish Goyal Vs. Max Bupa Health Insurance Co. Ltd. and others, 2018 (2) CLT, 205 (SC).

7.                On the contrary, the learned counsel for the OPs No.1 & 2 has argued that in the certificate issued by Mehra Hospital, it is categorically mentioned that the complainant was suffering from trigeminal neuralgia since 2009, but at the time of taking the policy, he had not disclosed this fact and as such, violated the terms & conditions of the policy. The OPs No.1 & 2 have rightly repudiated the claim vide letter dated 19.06.2017 (Annexure OP2).

8.                Admittedly, the complainant was duly insured for a sum of Rs.2 lacs for the period from 26.11.2016 to 25.11.2018 with the OPs No.1 & 2 vide policy document Annexure OP-1. From the letter dated 19.06.2017 (Annexure OP2), it is clear that the OPs No.1 & 2 have repudiated the claim of the complainant for the reason that “The medical history details of trigeminal neuralgia since 2009 is not revealed while taking the policy in the proposal form”. The contention of the complainant is that OPs No.1 & 2 had wrongly alleged that he was not suffering from trigeminal neuralgia since 2009. In support of this contention, he has produced certificate dated 30.05.2017 (Annexure C-8) and prescription slip dated 13.04.2017 (Annexure C-10) issued by Mehra Hospital. From the perusal of said documents, it is evident that the doctor had prescribed Mazetol 200 mg, but in the said documents, there is nowhere mentioned that complainant was suffering from trigeminal neuralgia since 2009. However, the learned counsel for the OPs No.1 & 2 has drawn our attention to other certificate issued by Mehra Hospital, wherein, it has been mentioned that the complainant was suffering from trigeminal neuralgia since 2009. No doubt, the said document on which the OPs No.1 & 2 are relying upon, is placed on the case file, but the same has not been tendered by them in their evidence. Even otherwise, the said document cannot be relied upon to go against the complainant, because, it is a settled preposition of law that when there conflicting documents on the one issue, then one which goes in favour of the complainant/consumer, shall hold the field. No other cogent document has been produced by the OPs No.1 & 2 to prove this fact that the complainant was suffering from trigeminal neuralgia since 2009. As such, we do not hesitate to conclude that OPs No.1 & 2 could not prove their case. In this view of the matter, we hold that the OPs No.1 & 2 by not paying the claim amount to the complainant, have committed in deficiency in services and are thus, not only liable to pay the claim amount of Rs.2 lacs to the complainant, but are also liable to compensate him for the mental agony and physical harassment suffered by him alongwith litigations expenses.

9.                In view of the aforesaid discussion, we hereby dismiss the present complaint against OPs No.3 & 4 and allow the same against OPs No.1 & 2 and direct them in the following manner:-

1. To pay the claim amount of Rs.2 lacs alongwith interest @ 7% per annum w.e.f. 19.06.2017 i.e. the date of the repudiation of claim, till its realization.
2. To pay Rs.3,000/- as compensation for mental agony and physical           harassment suffered by the complainant.
3. To pay Rs.2,000/- as litigation expenses.

 

                   The OPs No.1 & 2 are further directed to comply with the aforesaid directions jointly and severally within the period of 30 days from the date of receipt of the certified copy of this order, failing which, the awarded amount shall carry interest @ 9% per annum for the period of default. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced on :18.07.2019.

 

 

 

          (Vinod Kumar Sharma)           (Ruby Sharma)               (Neena Sandhu)

              Member                                  Member                       President