Before the District Consumer Disputes Redressal Forum, Rohtak.
Complaint No. : 510.
Instituted on : 01.09.2017.
Decided on : 19.09.2019.
Naresh, age 45 years, s/o Chandgi Ram R/o Village-Bhainsru Khurd, Distt. Rothak.
..………..Complainant.
Vs.
Apollo Munich Health Insurance Company Ltd., 2nd & 3rd Floor, ILBAS centre, Plot No.404-405 Udyog Vihar, Phase-III, Gurgaon-122106, through its Manager.
……….Opposite party.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. RENU CHAUDHARY, MEMBER.
MS. TRIPTI PANNU, MEMBER.
Present: Sh.Ajay Ohlan, Advocate for the complainant.
Sh.Y.S.Dalal, Advocate for opposite party.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Present complaint has been filed by the complainant with the averments that complainant has obtained a health policy from the respondent under Easy health Individual Standard vide policy no.110103/11001/10000387963-03 started from 24.04.2013 and this policy has been renewed from time to time till 01.07.2016 to 30.06.2017. That the complainant was got admitted in Maharaja Agarsen Hospital, West Punjabi Bagh, New Delhi which is paneled hospital of respondent and he remained admitted in the said hospital from 05.04.2017 to 07.04.2017 and spent an amount of Rs.36039/- on his treatment. That complainant intimated to the respondent about his admission in the hospital and submitted all the treatment papers and bills to respondent and applied for insurance claim. But the respondent has denied to pay the claim amount to the complainant on the ground that complainant has not disclosed about his ailment. That the act of opposite party is illegal and amounts to deficiency in service. Hence this complaint and it is prayed that opposite party may kindly be directed to pay the claim amount of Rs.36039/- alongwith interest, compensation and litigation expenses to the complainant.
2. On notice opposite parties appeared and filed their written reply submitting therein that upon receipt of the claim, opposite party made investigation and found that the insured had received treatment of “Coronary Angiography for the Triple Vessel Disease in Heart” at Maharaja Agarsen Hospital, New Delhi. He was treated at the said hospital from 14.03.2012 to 24.03.2012. The proposal form in the above policy was submitted on 23.04.2013 as per which the policy was issued in the name of insured Mr. Naresh. Since the actual medical condition of the Insured was not disclosed in the said proposal form dated 23.04.2013 and the said non-disclosure amounted to Non-disclosure of a material fact & misrepresentation, the opposite party had repudiated the cashless request. That complainant himself has violated the terms and conditions of the proposal form as well as policy and hence, is not entitled for any claim. That there is no deficiency in service on the part of opposite party and it is prayed the claim may kindly be dismissed with costs.
3. Both the parties led evidence in support of their case.
4. Ld. Counsel for the complainant in his evidence has tendered affidavits Ex.CW1/A, documents Ex.C1 to Ex.C33 has closed his evidence on dated 09.10.2018. On the other hand, ld. Counsel for the opposite party has tendered affidavit Ex.R1 and has closed his evidence on 25.01.2019.
5. We have heard ld. counsel for the parties and have gone through the material aspects of the case carefully.
6. In the present complaint, respondent officials placed on record affidavit of Ms. Deepti Rustagi, Vice President, Legal & Compliance, Apollo Munich Health Insurance Company as Ex.R1. Except this affidavit, no any other document has been placed on record by the respondent. As per written statement and affidavit filed by the opposite party, complainant took treatment from Maharaja Aggarsen Hospital w.e.f. 14.03.2012 to 24.03.2012. Regarding the above mentioned fact, respondent officials have not placed on record any document to prove that the complainant took treatment from Maharaja Aggarsen Hospital regarding the ailment of Coronary Angiography Triple Vessel treatment. Moreover as per the discharge summary Ex.C16, the complainant was admitted in Maharaja Aggarsen Hospital on dated 05.04.2017 to 07.04.2017 with complaints of vomiting, decreased oral intake for 2-3 days, fever since 3-4 days and joint pain for 15 days. The perusal of this discharge summary itself shows that the complainant was never treated in Maharaja Aggarsain Hospital prior to 05.04.2017. Hence the repudiation of claim by the opposite party is illegal and amounts to deficiency in service. As such complainant is entitled for the claim amount as per final bill issued by the Hospital Ex.C13 amounting to Rs.36039/- say Rs.36040/-(rounded off).
7. In view of the facts and circumstances of the case, complaint is allowed and it is directed that opposite party shall pay the amount of Rs.36040/-(Rupees thirty six thousand and forty only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 01.09.2017 till its actual realization and shall also pay an amount of Rs.2000/-(Rupees two thousand only) as compensation and Rs.2000/-(Rupees two thousand only) as litigation expenses to the complainant within one month from the date of decision.
8. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
19.09.2019.
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Nagender Singh Kadian, President
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Renu Chaudhary, Member.
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Tripti Pannu, Member.
