Delhi

East Delhi

CC/1162/2014

N.K SHARM - Complainant(s)

Versus

APOLO MUNICH HEALTH INS. - Opp.Party(s)

07 Mar 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.     1162/2014

                                                                                                   Date of Institution               23/12/2014

                                                                                                   Order reserved on               07/03/2018        

                                                                                                   Date of Order                       12/03/2018                                                                                     

 

In matter of -

Mr N K Sharma, adult   

R/o- 73, Gali no. 7E

Molarbandh Extn., Badarpur

New Delhi 110044.……….……………...………………………………..….Complainant

                             

                                      Vs

1- The Branch Manager

Apollo Munich Health Insurance Co. Ltd.

204 Laxmi Jeet Building

Laxmi Nagar District Centre, Delhi 11092  

 

2-M/s Apollo Munich Health Insurance Co. Ltd.

2^nd &3^rd Floor, ILABS Centre,

Plot No. 404-405, Udhyog Vihar, Phase III  

Gurgaon, Haryana 122021

 

3-Mr Taras Munjal

Apollo Munich Health Insurance Co. Ltd.

204 Laxmi Jeet Building

Laxmi Nagar District Centre, Delhi 11092  …..…….….…………..Opponents

 

Complainant………………………………..In person

Opponent 1,2 &3………………………….AVA Law Asso. Advocates

 

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 ported his family medicare policy from United India Assurance Co. which was in existence from 10/02/2009 having three members insured for a sum of Rs 1.5 lacs each to up to 09/02/2013 (CW1/5A to CW1/5D). It was stated that complainant preferred his policy from present OP and took Easy Health Individual Standard Mediclaim policy for his three members for a sum of Rs 2 lacs each and after getting all the facts and issues with benefits, complainant signed policy proposal form on dated 21/12/2012 and paid Rs 9069/- as premium vide policy proposal form no. 1101951427 (CW1/1). He stated that OP advised necessary medical tests to be done, so all the tests were done and reports were submitted and thereafter he received policy documents with policy terms and conditions effective from 10/02/2013 to 09/02/2014 vide policy no. 110105/11001/1000349279 (CW1/3). Thereafter the said policy was renewed for two years from 10/02/2014 to 09/02/2016 and added bonus accordingly (CW1/4).

 

Complainant stated that he got admitted in Asian Hospital, Faridabad for hypertension and heart related problems from 06/02/2014 to 08/02/2014 (CW1/8). The treating hospital applied for Cashless requirement from OP on 06/02/2014 (CW1/7), but cashless was rejected by OP giving reason of non  disclosure  of  material  facts, so complainant paid hospital bill of sum of Rs 33,054/-(CW1/8B). It was stated that OP had also terminated the policy from 07/02/2014 for non disclosure of material facts as Hypertension in his policy proposal form (CW1/9 & 9A). It was also stated that complainant wrote number of letters for knowing the reason of rejection of his claim and policy (CW1/10 to CW1/13), but OP did not consider his letters and reminders, but later OP paid in parts of claim amount Rs 13000/-, Rs 1914/- and Rs 654/-when claim was rejected. He received sum of Rs 15568/-only up to 26/06/2014. When no balance amount was paid or replied his letters from OP, complainant gave notice on 31/10/2014 for payment of balance amount, but did not get any reply or payment so filed this complaint and claimed treatment bill Rs 33054/-with compensation for harassment of Rs 5 lacs and litigation charges.

 

OP1 submitted written statement on behalf of OP2 and OP3 and denied all the facts as wrong and incorrect as alleged in the complaint. It was stated by OP that rejection of claim and termination of policy was justified under policy terms and conditions as complainant has intentionally hidden material facts pertaining to Hypertension and Coronary Artery diseases (CAD) with Unstable Angina since 2010 and complainant did not disclosed in the policy proposal form clause 6(A)I, 6(B) xv, xvi, xvii and xviii at the time of signing the policy proposal form and thus violated the fundamental law of contract. So, the entire process was ab-initio and there was no contract with OP. Hence this complaint to be dismissed with cost. It was also submitted that complainant did not mentioned about prior insurer status for his policy from UIAC at the time of taking portability benefits from present OP. OP also submitted that previous insurer, UIAC, shared incomplete and incorrect informations to OP, so UIAC would also be made as a necessary party to depose the correct informations.

 

OP submitted that their repudiation and termination of policy was as per the terms and conditions of the policy for which OP took reference of law laid down in Maya Devi vs LIC, RP 2091/2007, NC and PC Chacko & others vs Chairman LIC, AIR 208 SC 424 where it was stated that violation of provisions of Section 45 of the Insurance Act amounts to repudiation if found fraudulent act of complainant. Other reference of Mithoolal Nayak vs LIC, AIR, 1962 SC 814 SC, where it was laid down that suppression of any material fact or statement and fraudulently made by the policy holder amounts repudiation of claim. Also in UIAC vs Subhash Chandra, RP 469/2006 NC, it was held that knowledge of material facts in the mind of complainant which are material to disclose has been intentionally suppressed so OP was justified to repudiate insurance policy.  Here in this case presence of CAD and Unstable Angina since 2010 amounts to material facts to OP and that being so, claim was repudiated as per terms and condition of the policy and termination of policy was justified. Also putting signature on policy proposal form after reading it properly clearly amounts suppression of facts before OP in reference to “Satwant Kaur Sandhu vs New India Assurance Co. Ltd.” in CA 2776/2002/SC decided on 10/07/2009. Taking reference of facts and evidences as there was clear suppression of material facts by the complainant. Hence this complaint be dismissed with cost.

 

The complainant filed his rejoinder to the written statement submitted by OP1&2 and denied all replies filed. It was stated that all his facts and contents were correct and true in his complaint. Complainant also submitted his evidence by way of affidavit and affirmed himself on oath that all the evidence in complaint were correct and true to his knowledge and were on record. He also stated that his previous mediclaim policy was a cashless and had taken two claims for hypertension and heart related ailments from UIAC where his sum assured was 1.5 lacs as individual policy. He further stated that at the time of taking policy from present OP1, all the facts were disclosed to the agent/OP3 and were also entered in the policy proposal form and all related medical tests were done which were normal, but OP1 had given Floater policy and had ceased sum assured to 1.5 lacs pertaining to his ailments. OP1 through OP2 had also given portability benefits to complainant for clauses Sec 6B, Sec 6C and Sec 6D to all his three family members (Ex CW1/3A) from very first policy. Even though OP1 had intentionally repudiated his genuine claim and terminated the policy.  Thus, his claim be given policy be restored.

OP1&2 submitted evidences on affidavit through Ms. Deepti Rustogi, Vice President Legal, working with OP1 & OP2, affirmed on oath that policy was issued after complainant filled his policy proposal form which had been on record and policies were always issued based on information given by the policy seekers and based on good faith. It was revealed that complainant had taken two claims from UIAC for the same ailment, but did not disclose in the proposal form. The non disclosure of Hypertension and CAD with Unstable Angina which in 2010 had violated the terms and condition of the said policy so his claim repudiated and policy was terminated. Thus rejection was justified based on terms and condition of the policy. It was submitted that the said policy was issued on the facts submitted by the complainant in his policy proposal form and he had intentionally hidden all the material facts before the present OP and even in Portability form he did not disclose any material pertaining to his ailments for which he took claims also (Ex OPW1/1). It was stated that before cancelling the policy, a notice was given to the complainant as per IRDA guidelines under Section 7 on dated 07/02/2014. So their termination was justified. So, the present OP do not admit any liability towards any claim, compensation or refund of any nature.       

 

Both the parties filed their written synopsis 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, we framed three clarifications as under –

1. Whether claim rejection was justified by OP under Portability?
2. Whether complainant is liable for claim under continuity of mediclaim tenures?
3. Status of Claim in reference to citations submitted by OP and complainant’s status?

1- Whether claim rejection was justified by OP under Portability?

After careful examining the policy proposal form and medical tests reports on record and complainant’s status, we noticed few things as –

1. Policy proposal form was not filled by the complainant (by seeing the signatures on record) and merely filling “NO” in all the columns showed that complainant had not being asked properly by the person (OP3) who so ever form was filling whereas complainant had put his signatures on all the documents and stated in his affidavit that all facts about his previous claims pertaining to the ailments (CAD, Hypertension) were told to OP3. It is also very important to see the medical reports as the reports were given by the pathologist (dr.) who is a non clinical person and as per Allopathy protocol, Medical Report has to be given by a physician, but not by a pathologist. This clearly means that OP had procured the reports of their own in hurry from their panel labs. This is a usual practice adopted by the insurer and in no case, policy seeker get his reports done and submits of his own. When he had CAD, Hypertension and Unstable Angina, ECG cannot be normal as shown on record. It is clear that Hypertension is the basic cause of CAD and Unstable Angina is a further manifestation of Hypertension.
2. More so, in portability by the person from other insurer (UIAC) to the present one (AMHI), previous claim status was given by the complainant and present OP have given portability benefits by excluding clauses 6B,C and D for a sum assured 1.5 lace whereas his policy was of 2 lacs. It means, complainant under floater policy can avail benefits up to 1.5 lacs for Cardiovascular ailments in future, but NO Exclusion was put by OP1&2. For all other ailments, rest terms and conditions would be available.   
3. It is acceptable that scrutiny of related claims is always done before passing the claim or rejecting under exclusion clauses. Though this was done in this case, but portability benefits were neglected which had been given before issuing the said policy and thereafter rejection was done. So we are not satisfied with these types of approaches adopted by the OP, hence rejection was not justified.

2- Whether complainant is liable for claim under continuity of mediclaim tenures -

It is to be noted that complainant had continuity of his mediclaim tenure since 2009 without break till Feb. 2014. He had taken two claims from previous Insurer (UIAC) and details were declared and available by the OP1. The two claims were in the second year of policy with UIAC and were passed and same had in present policy. No major invasive procedure was done except conservative line of treatment was given.  Merely presence of Hypertension since 2010 and taking conservative line of treatment by complainant and more so, declaring in portability and present OP giving benefits after ceasing sum assured to previous insurance co. (UIAC) as 1.5 lacs against 2 lacs and subsequently repudiating claim and terminating policy itself amounts deficiency  of present OP1&2.   

Here, after seeing the terms and conditions of the said policy, the present insurer/OP has considered as a new exclusion clauses without considering meaning of Sec. 6 B,C & D under exclusion clauses where OP has given benefits. OP had knowledge that complainant had his mediclaim policy earlier also from 2009. So, under portability condition, OP should have given portability benefits of policy which was not done. Thus, repudiation for Hypertension and its related complications are not justified in reference to the continuity of policy tenure wef 2009.  

3- Status of Claim in reference to citations submitted by OP ?      

After going through the law laid down in the citations on record, the rejection was justified, but does not apply in case of portability case where continuity of mediclaim policy is continued from 2009 onward. Also considering nature of work and mentioned in Anne, 1 & 2 by OP as cloth trader and home tuitions means complainant is not very much educated to understand all the issues pertaining to portability and related benefits. OP accepting pathologist ‘medical opinion’ (though not acceptable) as ‘normal’ does not looks rejection justified. Also OP paid part of claim amount Rs 15568/-in parts out of claimed amount Rs 33054/-after repudiating claim and terminating policy, itself amounts deficiency in services.    

Hence, we come to the conclusion that OP1 & OP2 are deficient in their services, so the following order is passed as under—

1. OP 2 shall reimburse balance claim amount Rs 17486/- with 6% from 26/06/2014 within 30 days from receiving the order.  
2. We also award Rs 7000/-as compensation for harassment with Rs 3000/-as litigation charges.
3. OP2 shall restore the terminated policy in its original status wef 2014 under same portability benefits within stipulated time.  
4. If order is not complied in time essence, then complainant shall be entitled to recover entire awarded amount with same interest from the date of order, till realized.
5. No other order to cost.    

 Copy of this order be sent to the parties as Regulation 18 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