Delhi

East Delhi

CC/897/2013

SUNIL KR. - Complainant(s)

Versus

APOLLO MUNICH - Opp.Party(s)

09 Oct 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.       897/2013

                                                                                                   Date of Institution               08/10/2013

                                                                                                   Order reserved on               09/10/2018        

                                                                                                   Date of Order                       12/10/2018                                                                                  

In matter of -

1-Mr. Sunil, adult      

s/o- Sh Ranjeet Singh  

 

2- Smt Kavita, adult

w/o- Mr Sunil

R/o- F-24, Village  Gazipur, Delhi 110096 ……….…………………….….Complainants

                             

                                                                                        Vs

1-The Manager

Apollo Munich Health Insurance Co. Ltd.

Plot no.9, 2^nd Floor, Ansal Laxmi Deep Building

District Centre, Laxmi Nagar, Delhi 11092         

 

2 The MD,

 Apollo Munich Health Insurance Co. Ltd.

10^th  Floor, Tower B, Building no. 10,

DLF Cyber City Phase II, Gurgaon, Haryana 122002 ……….………..Opponents

 

Complainant’s Advocates……………..Mr N K Ray

Opponent’s Advocate……………………Avinash Mohapatra 

 

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 took Easy Health Family Floater Plan mediclaim policy from OP1 / Apollo Munich Health Insurance (ExCW1/1) from Noida branch sales office vide policy no. 110102/11111/1000212945 with terms and conditions (ExCW1/1A) for  sum  insured  Rs 3 Lacs

valid for two years from 13/06/2011 to 12/06/2013 after paying premium amount Rs 11,784/-and received individual ID card (Ex CW1/2).

Wife of complainant, Mrs Kavita aged 25 years, fell down in bathroom in the morning at 5.40 am of 20/02/2013 and sustained severe injuries over her body and blood started coming out from vagina, so she was admitted at Ganpati Maternity Hospital at Noida at about 6.15 am on the same date in emergency conditions (Ex CW1/3,3A,3B and 3C). She remained admitted up to 1 pm and after paying bill of Ganpati Hospital of Rs 13101/-was referred to Kailash Hospital at Noida where she re-admitted from 20/02/2013 to 25/02/2013. As cashless was denied by OP 2, so complainant paid treatment bill of Rs 1,61,954/-(Ex CW1/4,4A,4B and 4C).

 

Complainant filed his claim with OP 1 on 07/03/2013 and the same was repudiated on 13/03/2013 under exclusion clause 6(c) Ex CW1/6 & 7). Complainant persuaded his claim case with OP 1 office, but did not get any reply, so filed this complaint and claimed total treatment bill of Rs 1,61,964/-with 24% and compensation for harassment a sum of Rs 2 Lacs and litigation charges Rs 21,000/-and business loss of Rs One Lac.

OP2 jointly submitted written statement and denied all the facts as wrong and incorrect as alleged in complaint. It was admitted that the said policy was issued after complainant filled policy proposal form himself and put his signatures on it (Anne. R1) and OP had issued policy for two years with complete policy terms and conditions (Anne. R2 colly). It was stated that claim was rightly rejected under exclusion clause 6 (c) which stated as –

     The illness and treatment listed below will be covered subject to a waiting period of 2 years  

as long as in the third policy year the insured person has been insured under an easy Health any break :

• Illness,
• Treatments ….-…dilatation and curettage (D&C); Hysterectomy for menorrhagia, or 

Fibromyoma or prolapsed of Uterus unless necessitated by malignancy………

Here in this case, complainant’s wife/insured was admitted in Kailash Hospital, Noida and received cashless request on 20/02/2013 which was rejected on provisional diagnosis of Atonic Uterus with severe bleeding from vagina and proposed line of treatment was Total Abdominal Hysterectomy and estimate was given for a sum of amount Rs 1,65,929/- (Ex OPW1/R3).

As TAH was covered after 2 years from inception date (13/06/2011) and complainant had not completed two years of policy tenure which was a required exclusion period, so cashless claim was rejected vide letter dated 21/03/2013 u/s Section 6 (c) (Ex OPW1/R4).

 

Insured had undergone D&E vide claim no. ID 111948 from Ganpati Hospital, Noida. OP had thoroughly scrutinised USG report of Ganpati Hospital which revealed that NO INTERNAL INJURIES to abdominal wall internally or externally found or had no findings mentioned in the treatment papers or treatment to injuries were given. These findings were contrary to the facts narrated in complaint where it was stated as his wife sustained severe injuries due to fall in bathroom and showed the intention of insured for the removal of uterus. Thus surgical procedures as D&C and TAH were done. These procedures came under exclusion clause  Section 6 (c) of policy terms and conditions.

Kailash Hospital had also mentioned that there were no injuries to the abdominal parts. Total Hysterectomy was done as Uterus was relaxed and had no contractible strength. This procedure fall under exclusion condition of policy, so rejection was done. These procedures violate policy terms and conditions, so repudiation was justified and thus prayed for dismissal of complaint.   

Complainant filed rejoinder and denied all the replies submitted by OP. It was stated that violation of policy terms and condition was nowhere applicable and repudiation under exclusion clause 6 (c) was not applicable. It was a case of accidental fall and his wife sustained injuries over her body and OP had wrongly submitted facts, hence, facts of his complaint be accepted and repudiation may be termed as unjustified.

Complainant submitted evidence through his own affidavit and stated on oath that his all facts and evidences were correct. Complainant restated that OP had issued policy with all the facilities like cashless and passing of claims without hassle. Complainant stated that without properly investigating and verifying evidences, OP rejected their claim. Thus the complainant suffered heavy financial loss and mental agony. Complainant relied upon his evidences as Ex CW1/1 of ID of insured, Ex CW1/2 as policy copy, Ex CW1/7 as refusal letter, and treatment details of previous hospital, Ganapati Hospital as Ex CW1/8. So, complainant prayed that his all evidence were correct and claim be passed.  

OP also submitted evidence on affidavit through Mr Sameer Bhatnagar, Vice President-Legal & COO with OP and affirmed on oath that repudiation of claim was justified as per policy terms and conditions. It was admitted that policy no. 110102/11111/10090212945 was issued to complainant from 13/06/2011 to 12/06/2013 for two years and D&C and TAH were not payable within two years. As the policy was issued on good faith and no medical tests were advised because complainant and insured were less than 45 years. D&C and TAH were not payable within two years.

D&C and TAH was not covered within two years of policy tenure (Ex OPW1/R4. It was further stated that both the hospitals had treated for D&C and TAH. The history of insured in the treatment records showed that she had under gone number of abortions earlier and had alive children.

It was further stated that complainant had narrated all wrong facts in his complaint as no injury marks were found and also had nowhere bony injury or muscular injury found, where in complaint it was stated that his wife sustained major injuries and had heavy bleeding from vagina. When these facts were analysed from the treatment records and USG reports which showed all normal findings and no internal injury findings were seen. Thus repudiation of his claim was justified.

Both the parties submitted their written arguments and taken on record.

 

Arguments were heard from both party’s counsels and after perusal of file, order was reserved. Before coming to the conclusion of this case, few clarifications are required to be discussed as under –

1. Whether claim rejection was justified by OP under policy terms and conditions?
2. Whether complainant was entitled for claim?

Point 1- Whether claim rejection was justified by OP under policy terms and conditions?

In reference to clarification no. 1, it has been seen for ailment “Severe Abdominal Injuries leading to D&C followed by TAH (Total Abdominal Hysterectomy)”where complainant’s main defence was due to accidental fall in bathroom, his wife sustained severe injuries and led vaginal bleeding. It was seen that in absence of any injury findings over the body and lower abdomen, supported previous multiple abortions which caused decreased Uterine muscular leading to Atony of Uterus and the line of treatment adopted was a standard one to remove the Uterus to save the life of insured/wife of complainant. It is done through abdominal wall route. Atony of the uterus, also called uterine atony, is a serious condition that can occur after childbirth or failed threatened Abortion. It occurs when the uterus  fails to contract after the delivery of the baby or in abortion. It can lead to a potentially life-threatening condition known as postpartum hemorrhage, hypovolamic shock and collapse. So, adopted line of treatment is TAH as age of the wife of complainant was just 26 years and TAH is usually not done.

There are numerous causes of D&C. Main are for diagnostic purpose and for abortions. Here clots were removed at Ganpati Hospital as bleeding was present, but when bleeding did not stop, complainant’s wife was shifted to Kailash Hospital at Noida, UP where total abdominal hysterectomy was done to save the life of the insured. The process to remove the Uterus was a standard line of procedure adopted by Kailash Hospital. There were no internal injuries or bleeding point which could be termed as “Accidental Injury”. Hence, repudiation of claim was justified under the terms and conditions of the policy by OP.

It is an accepted law that damages must be proximate to the cause which complainant failed to prove.      

Point 2 - Whether complainant was entitled for claim-

After careful examining the policy terms and conditions and repudiating claim under exclusion clause 6 (c) which reads as -“The illness and treatment listed below will be covered subject to a waiting period of 2 years as long as in the third policy year the insured person has been insured under the policy without break -

• Illness,
• Treatments ….-…dilatation and curettage (D&C); Hysterectomy for menorrhagia, or 

Fibromyoma or prolapsed of Uterus unless necessitated by malignancy………”

After going through the law laid down for the rejection of claim was justified based on the terms and conditions of the policy pertaining to the non disclosure of the material facts in treatment records and facts of the complaint. The law laid down in various citations clearly speaks about strict adherence of policy terms and condition and any fraudulent act is found, claim rejection will be justified and termination is to be done by Insurer.   

We have taken reference of certain citations applicable here to justify the rejection of claim as- 

Mithoolal  Nayak  vs  LIC of India, AIR 1962 SC 814,

Haji Ahmed Yar Khan vs Abdul Gani Khyan, AIR 1937 Nag 207,

United India Insurance Co. Ltd vs Subhash Chandra in RP 469/2006, NC

LIC of India vs Smt Satwant Kaur Sandhu in RP 3138/2006, NC.

 

where it was laid down that policy is issued on Good Faith only and if non disclosure of material fact was found, repudiation would be justified and contract would be void ab-initio.

It was stated that complainant’s wife suffered severe abdominal injured due to accidental fall in the bathroom led heavy bleeding from vagina.  After seeing treatment documents, it was due to loss of contractibility of Uterine musculature (Atony) and even after D&C, bleeding could not be stopped, so was referred to Kailash Hospital where TAH was done. In absence of injury marks over abdominal area and internal parts as vagina and Uterus or intestine, history of severe accident was not reliable. This proves that no injuries occurred in bathroom due to fall and thus rejection was justified based on policy terms and conditions by OP. There was also no concrete evidence submitted by complainant to prove his allegation of deficiency in services adopted by OP.

Hence, we come to the conclusion that complainant has failed to establish deficiency in the services of OP in repudiating claim of complainant.

 

 

That being so complaint deserves to be dismissed, so dismissed without any order to cost.    

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

 

(Dr) P N Tiwari  Member                                                                         Mrs  Harpreet Kaur  Member                                                                                       

                                                 

                                                       Sukhdev Singh  President