Chandigarh

DF-I

CC/861/2014

Kirpal Singh - Complainant(s)

Versus

Apolo Munish Health Insurance Co. Ltd. - Opp.Party(s)

Vishal Goel

20 Jul 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

============

Consumer Complaint  No	:	CC/861/2014
Date  of  Institution	:	29/12/2014
Date   of   Decision	:	20/07/2015

 

 

 

 

 

 

Kirpal Singh son of Sarwan Singh, resident of Flat No.1006, Chief Auditor Society, Sector 50-B, Chandigarh.

 

….Complainant

Vs.

 

(1)  Apollo Munich Health Insurance Co. Limited, SCO 50-51, 4^th Floor, Sector 34-A, Chandigarh, through its Authorized Officer.

 

(2)  Europ Assistance India Pvt. Limited, 301, C-Wing, Business Square, Andheri Kurla Road, Chakla, Andheri (East), Mumbai through its Authorized Officer.

 

…… Opposite Parties

 

 

BEFORE:   SH. P.L. AHUJA               PRESIDENT

MRS. SURJEET KAUR           MEMBER

          SH. SURESH KUMAR SARDANA     MEMBER

 

For Complainant	:	Sh. Vishal Goel, Advocate.
For OP No.1	:	Sh. Nitin Thatai,Advocate.
For OP No.2	:	Ex-parte.

 

PER SURESH KUMAR SARDANA, MEMBER

 

]

 

          The facts which are necessary for the adjudication of the present Complaint are conceptualized hereinafter. The Complainant had purchased a Travel Policy namely, ‘Easy Travel Individual’ from the Opposite Parties, for the period from 18.8.2012 to 13.2.2013 (Policy Annexure C-1). During the period of his stay at abroad, the Complainant become ill on 11.9.2012 and had to take treatment from a doctor, for which he paid AUS $40. Further, the Complainant had paid AUS $143.20 on medical investigations and also incurred AUS $235.84 on the purchase of medicines (Annexure C-2 to C-4). In this way he spent on his treatment an amount of AUS $419.04. It has been alleged that on coming back to India on 18.01.2013, the Complainant lodged a claim with the Opposite Parties, supported with the requisite documents. However, the Opposite Parties rejected the claim of the Complainant, on totally fake grounds, vide letter dated 06.05.2013 (Annexure C-7), which according to the Complainant amounts to deficiency in service. Hence, the present Complaint.  

 

2.     Notice of the complaint was sent to Opposite Parties, seeking their version of the case. However, nobody appeared on behalf of Opposite Party No.2 despite service, therefore, it was proceeded ex-parte on 18.02.2015.

 

3.     Opposite Party No.1, in its written version, while admitting the factual matrix of the case, has pleaded that the Complainant travelled to Australia and during the coverage of the policy on 11.09.2012 had taken a treatment from a doctor in Australia and paid a consultation fee of AUS $40 and on the reference/advise of the said doctor got medical investigation and spent AUS $143.20, purchased medicines from the Chemist and spent AUS $235.84, totaling to AUS $419.04. It has been submitted that since claim of the Complainant comes under the exclusion clause, therefore, his claim was rightly rejected on the ground that his consultation with the doctor was for tiredness and blood test was also done which revealed iron and vitamin B12 deficiency and there was no acute medical emergency noted or measures to reveal acute pain/distress. Denying all other allegations and stating that there is no deficiency in service or unfair trade practice on its part, Opposite Party No.1 has prayed for dismissal of the complaint.

 

4.     The Complainant also filed rejoinder wherein the averments as contained in the complaint have been reiterated and those as alleged in the written statement by the Opposite Party No.1 have been controverted.

 

5.     Parties were permitted to place their respective evidence on record, in support of their contentions.

 

6.     We have heard the learned Counsel for the parties and perused the record, along with the written arguments filed on behalf of both the sides.

 

7.     It is observed that during the period cover of the policy in question, the Complainant visited Australia. The age of the Complainant is reported to be 65 years. The Complainant had consulted a Doctor due to feeling of tiredness which could be due to illness. Section 1 of the Terms & Conditions states as below:-

 

“Section:1 Medical Treatment, Assistance & Evacuation: If any insured Person suffers an illness or Accident during the Risk Period that alters the Insured Person’s state of health and requires immediate medical treatment in order to maintain life or relief immediate pain or distress, then we will pay:

1)    Medical Treatment………….”

 

 

8.     We are of the view that the Complainant consulted the doctor, underwent various tests and took medicines, as he suffered illness during the risk period and the development of tiredness had altered the Complainant’s state of health at that age and thus required immediate consultation of the Doctor and medical treatment in order to relieve from immediate pain/ distress. The Opposite Parties are therefore liable to pay all the medical expenses for outpatient treatment. The said treatment is in no way covered under Special Exclusions to Section 1. 

 

9.     In the light of above observations, we are of the concerted view that the Opposite Parties are deficient in rendering proper service to the complainant. Hence, the present complaint of the Complainant deserves to succeed against the Opposite Parties, and the same is allowed, qua them. The Opposite Parties are, jointly and severally, directed to:-

 

[a]  To pay an amount of rupees equal to AUS $ 419.04 to the Complainant;

 

[b]  To pay Rs.20,000/-on account of deficiency in service and causing mental and physical harassment to the Complainant; 

 

[c] To pay Rs.10,000/- as cost of litigation;

 

10.     The above said order shall be complied within 30 days of its receipt by the Opposite Parties; thereafter, they shall be liable for an interest @12% per annum on the amount mentioned in per sub-para [a] & [b] above, apart from cost of litigation of Rs.10,000/-, from the date of institution of this complaint, till it is paid. 

 

11.     Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

20^th July, 2015                                       

Sd/-

(P.L. AHUJA)

PRESIDENT

 

 

Sd/-

(SURJEET KAUR)

MEMBER

 

 

                         Sd/-

         (SURESH KUMAR SARDANA)

“Dutt”                                                                                            MEMBER