DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

BATHINDA

C.C. No. 511 of 20-08-2014

Decided on 08-06-2015

Jaswant Sharma aged about 50 years S/o Gopal Chand, R/o #5321, Malvia Nagar. Bathinda.

…...Complainant

Versus

Apollo Munich Health Insurance through its Managing Director/authorized person, 10^th Floor, Tower-B, Building No. 10, DLF Cyber City, DLF City Phase-II, Gurgaon.

.......Opposite party

Complaint under Section 12 of the Consumer Protection Act, 1986.

Quorum :

Sh. M.P.Singh. Pahwa, President

Sh. Sukhwinder Kaur, Member

Sh. Jarnail Singh, Member

Present :

For the Complainant : Sh. Sanjay Goyal, counsel for complainant.

For the opposite party : Sh. Vinod Garg, counsel for Opposite Party.

O R D E R

M.P.Singh. Pahwa, President

1. This complaint has been filed by Sh. Jaswant Sharma, complainant under Section 12 of the consumer Protection Act, 1986 (here-in-after referred to as 'Act').

2. Briefly stated, the case of the complainant is that his son namely Mischael Sharma purchased one Health Insurance Policy whereby he was insured for Rs. 5.00 Lacs. He paid Rs. 5302.27 to the opposite party and Policy No. 110101/11119/6000104198 valid from 31-5-2013 to 30-5-14 was issued. The policy was known as Optima Restore Insurance Policy. The complainant was nominee of the plan and it was cashless health insurance policy. It was told to the complainant that medical expenses upto Rs. 5.00 Lacs were to be paid by the opposite party and Max Healthcare Hospitals are in its list regarding cashless plan, but no separate terms and conditions or policy was issued to the complainant or his son.

3. It is further revealed that son of the complainant met with an accident on 16-5-14 near village Kot Shamir, Tehsil and District Bathinda, while driving his vehicle No. DL3CBZ-9723, I-20 car. He was taken to Max Hospital, Bathinda, by nearby villagers. DDR No. 29 dated 17-5-14 was also registered at P.S. Kotfatta. It is averred that complainant asked the officials of Max Hospital to start treatment and shown them insurance documents. E-mail was sent by the officials of Max Hospital to opposite party but it was responded by opposite party that they have removed the name of Max Hospital from their list. Complainant was to make the payment of treatment at once out of his pocket and later on it was to be reimbursed. The complainant with very difficulty arranged/borrowed money from his relatives and deposited Rs. 1,45,000/- with Max Hospital, Bathinda, otherwise officials of Max Hospital, Bathinda, were not ready to start the treatment. Son of complainant remained admitted in Max Hospital, Bathinda, from 17-5-14 1.30 a.m. to 23-5-14, 3 a.m. and Rs. 1,71,716.43 were paid by complainant out of his pocket.

4. It is also unfolded that son of the complainant could not be saved. After his death, claim was lodged with the opposite party. Proposal Form alongwith original bills regarding hospitalization, treatment charges, MLR, DDR certificates from doctors were submitted with opposite party on 13-6-14 but the opposite party is delaying the reimbursement on one pretext or the other.

5. It is averred that officials of the opposite party are illegally making calls demanding more and more documents which are already submitted by the complainant. As per desire of the opposite party, complainant sent duplicate bills to the opposite party as the original bills were stated to have been lost by opposite party. It is alleged that despite repeated e-mail and other efforts of the complainant, opposite party has not reimbursed the claim and due to this reason, the complainant has suffered mental tension and harassment. It is also alleged that there is clear cut deficiency in service on the part of opposite party for which the complainant has claimed Rs. 50,000/- due to mental tension, Rs. 15,000/- as litigation expenses in addition to claim amount of Rs. 1,71,716.43 with interest.

6. Upon notice, opposite party appeared through counsel and contested the complaint by filing written version. In written version, opposite party raised legal objections that intricate questions of law and facts are involved which require voluminous documents and evidence, which is not possible in summary procedure under the 'Act' and appropriate remedy lies in Civil Court; that complainant has concealed material facts and documents from this Forum as well as from opposite party; that complainant is not entitled to any relief; complainant has concealed the fact that he did not submit complete documents for finalization of decision and payment of claim; that complainant did not submit original lab report of Rs. 9,848/-, original cash paid receipt of Rs. 1,45,000/- and related prescription and investigation report for the bills submitted by him, therefore, claim could not be processed and decided by the opposite party. The opposite party is supposed to get the original documents and bills including documents stated above for proper decision of the claim and for making assure that the complainant has not received any claim/compensation qua the same cause of action from any other insurer or institution. That complainant is estopped from filing the present complaint by his own act and conduct; complainant is not consumer of opposite party, as such complaint is liable to be dismissed; that this Forum does not have any jurisdiction to try, entertain and decide the present complaint as the opposite party has no branch office within the territorial jurisdiction of this Forum and that the complaint is also to be dismissed for non-joinder of necessary party i.e Max Hospital, Bathinda.

7. The opposite party has further pleaded that as per standard practice of the opposite party, every proposer who applies for a policy by means of an application in the form of a standard Proposal Form (here-in-after referred to as 'PF') wherein the proposer is required to fill in material information in the said PF. The opposite party received duly filled and signed PF dated 31-5-13 from Mr. Maschael Sharma for availing Optima Restore Individual Standard Policy seeking to cover himself. That believing the information and details provided by Mr. Mischael Sharma including the medical history in the PF to be true, correct and complete in all respects, giving due credence to the under writing norms of Apollo Munich, the opposite party issued an Optima Restore Individual Insurance Policy numbered as 110101/11119/6000104198 which was valid from 31-5-13 to 30-5-14. The policy holder has named his father Mr. J Rai Sharma (here-in-after referred to as 'complainant') as nominee in the policy. The policy kit containing all relevant documents was duly delivered to the proposer/policy holder Mr. Mischael Sharma giving him an opportunity to verify and examine the benefits, terms and conditions of the policy taken by him. Free look period of 15 days was given to the proposer from the date of receipt of policy documents to review the terms and conditions of the policy. If proposer has any objection to any of the terms and conditions, he has the option of cancelling the policy stating the reasons for cancellaton and he would be refunded the premium paid by him after adjusting the amounts spent on any medical check-up, stamp duty charges and proportionate risk premium. The proposer never approached opposite party within the Free Look Period or after that either seeking any clarification related to the policy or raising objection to any of the terms and conditions of the policy, implying thereby that the policy terms and conditions were acceptable to him.

8. It is admitted that opposite party received a cashless request from Max Hospital, Bathinda, for Mr. Mischael Sharma. The request was declined with the reason that cashless facility is not available in the Max Hospital, Bathinda, and the denial of cashless service was duly intimated to the hospital vide letter dated 17-5-2014. It is admitted that claim form for reimbursement of Rs. 1,71,716/- was received by the opposite party from the complainant on 16-6-2014. The policy holder insured was admitted in Max Hospital, Bathinda. As per claim form, the policy holder was admitted in the hospital from 17-5-14 to 23-5-14. On receiving documents submitted by the complainant, additional information was sought via Additional Information Request Form dated 1-7-2014 to evaluate the admissibility of the claim. Apart from other documents, original cash receipts for the payment of Rs. 1,45,000/-, treating doctor's certificate for any alcohol/drug influence details at the time of injury, related prescriptions and investigation reports were asked to be submitted by the complainant. Reminder was sent vide letter dated 14-7-14. It is further pleaded that opposite party received some of the documents from the complainant on 18-7-14 but still original cash receipts for the payment of Rs. 1,45,000/-, treating doctor's certificate for any alcohol/drugs influence details at the time of injury, related prescriptions and investigation reports and other mandatory documents were pending. The opposite party again issued letter dated 18-7-14 raising a request of all the pending mandatory documents. It is further averred that opposite party again received letter dated 19-7-14 alongwith few enclosures on 22-7-14 from the complainant. The complainant still failed to submit the original cash receipts of Rs. 1,45,000/-. The opposite party again issued letter dated 20-9-14 as a reminder for submission of documents for processing the claim. The opposite party received MLC copy from the complainant on 12-8-14 but complainant still failed to submit required original receipts of payment of Rs. 1,45,000/-. Letter dated 20-9-14 was again written asking the complainant to submit required mandatory documents. It is also stated that complainant has submitted original payment receipt of Rs. 26,716/- and for rest of the amount of Rs. 1,45,000/- only duplicate cash payment receipt was provided to the opposite party. In case the complainant submits the original payment receipts of Rs. 1,45,000/-, the opposite party shall evaluate the claim based on the merits of the medical documents. The complainant has submitted 6 duplicate deposit/advance receipt of total amounting to Rs. 1,45,000/- alongwith letter dated 19-7-14 but in the letter he has marked 'original cash paid receipts' whereas actually these are duplicate deposit/advance receipts.

9. The opposite party has also revealed that claim of the complainant is not repudiated but it is pending on merits as the complainant has failed to submit the required documents. As per opposite party, the claims are paid by any Insurance Company out of common pool of funds belonging to all policy holders of the company. It makes obligatory upon the Insurance Company to check the genuineness of each claim in the larger interest of all the policy holders.

10. On parawise reply also, the opposite party has controverted all the material averments of the complainant. It is further asserted that it is wrong that complainant was told that any medical expenses upto Rs. 5.00 Lacs are to be paid by the opposite party in any case. Coverage under the insurance policy and terms and conditions were strictly as mentioned in the insurance policy and these are binding upon the parties. It is also asserted that claim arising during the term of the policy is evaluated as per terms and conditions of the policy. The opposite party has substantially reiterated its stand as taken in legal objections and other objections, already detailed above. In the end, the opposite party has prayed for dismissal of complaint.

11. Both the parties were afforded opportunity to produce evidence. In support of his claim, complainant has tendered into evidence his affidavits Ex. C-1 & Ex. C-8, photocopy of policy schedule Ex. C-2, photocopy of certificate Ex. C-3, photocopy of receipt Ex. C-4, photocopy of bill Ex. C-5, photocopies of certificates issued by Max Hospital Ex. C-6 & Ex. C-7 and photocopy of Lab Investigation report Ex. C-9.

12. In order to rebut this evidence, opposite party has tendered into evidence photocopy of proposal form Ex. OP-1/1, photocopy of policy with terms and conditions Ex. OP-1/2, photocopy of letter dated 17-5-14 Ex. OP-1/3, photocopy of Claim Form with documents Ex. OP-1/4, photocopy of letters Ex. OP-1/5, photocopy of documents OP-1/6, photocopy of letter dated 18-7-14 Ex. OP-1/7, photocopy of letter Ex. OP-1/8, photocopy of letter dated 2-8-14 Ex. OP-1/9, photocopy of MLC and reminder Ex. OP-1/10, photcopy of sample receipts Ex. OP-1/11 and affidavit of Dr. Sriharsha A Achar Ex. OP-1/12.

13. Both the parties have also submitted written submissions.

14. We have heard learned counsel for the parties and gone through the record and written submissions of the parties.

15. Learned counsel for complainant has reiterated his stand as set up in the complaint and as detailed above. It is further submitted by the learned counsel for the complainant that material facts are not in controversy. It is admitted that son of the complainant namely Mischel Sharma was insured and Optima Restore Insurance Policy was got issued by him wherein complainant was nominee. The insured met with an accident and got treatment from Max Hospital, Bathinda. Unfortunately, he could not survive. The complainant submitted claim alongwith all the original documents but the opposite party has not reimbursed claim of the complainant. Only stand of the opposite party is that the complainant has not submitted original documents. The complainant has deposed on oath that he has already submitted original documents. Photocopies of the original documents are brought on record, copies of which have been submitted to the opposite party also. Non-payment of claim amount, amounts to deficiency in service on the part of the opposite party, as such complainant is entitled to compensation in addition to reimbursement of claim amount.

16. On the other hand, learned counsel for the opposite party has submitted that the complainant failed to submit the complete documents for finalization of claim. He has not submitted original Lab report of Rs. 9848/- ; original cash paid receipt of Rs. 1,45,000/- and prescription slip as well as investigation reports. As per insurance policy, copy of which is on the file as OP-1/4, the complainant is required to submit original bills which includes receipts/prescriptions. The only purpose to obtain original bills/receipts is to ensure that the claimant had not claimed the same reimbursement from any other insurer or source. Therefore, the fault is on the part of the complainant as he has failed to submit the original documents. There is no deficiency in service on the part of opposite party.

17. It is further submitted by the learned counsel for opposite party that the complaint is pre-mature. The categorical stand of the opposite party is that claim is not finally repudiated and it is still pending for decision on merits. Therefore, even if this Forum comes to conclusion that complainant has submitted all the documents, complainant is not entitled to the reimbursement of the entire amount till the final decision of the opposite party.

18. We have carefully gone through the record and have considered the rival contentions.

19. Undisputed facts are that the son of the complainant got issued Optima Restore Insurance Policy from the opposite party. He met with an accident and got treatment from Max Hospital, Bathinda, and unfortunately, he could not survive. The complainant was nominee of the insured. He submitted claim alngwith documents. From the stand of the opposite party, it appears that the claim of the complainant is pending only for want of some documents. As per opposite party, the complainant has not submitted original receipt to prove the payment of the amount of Rs. 1,45,000/- and test/Lab report to support the claim of Rs. 9,848/-. The sole purpose to obtain original documents is stated to ensure that the insured/complainant has not got the reimbursement from any other source. The complainant has placed on record copies of the all the receipts. The payment of Rs. 1,45,000/- is established from the bill issued by Max Super Speciality Hospital, Bathinda, copy of which is brought on file as Ex. C-5. It reflects deposited amount Rs. 1,45,000/-. The balance of Rs. 13,391.79 is also acknowledged deposited by patient. Therefore, this document proves payment of these amounts. Copy of Lab investigation report is also brought on file as Ex. C-9. Therefore, both these documents are already brought on record. The complainant has also furnished affidavit as Ex. C-8. In this affidavit, complainant has declared that no other claim has been lodged by him nor any claim has been received regarding medical claim of Mischel Sharma. He has also deposed that all the original receipts and bills were already submitted with the opposite party. In such circumstances, the conclusion is that the complainant has performed his part to meet the requirements of the opposite party. As such, non release/finalisation of claim, amounts to deficiency in service on the part of the opposite party.

20. For the reasons above, this complaint is partly accepted. The opposite party is directed to do as under :

    i) Decide the claim of the complainant without calling for any further documents/receipts from him.

    ii) Release the amount payable to the complainant alongwith interest @ 9% P.A. from the date of filing of this complaint i.e. 20-08-2014 till release of payment.

    iii) Pay litigation expenses to the tune of Rs. 5,000/-

21. The compliance of this order be made within 30 days from the date of receipt of copy of this order.

22. The complaint could not be decided within the statutory period due to heavy pendency of cases.

23. Copy of order be sent to the parties concerned free of cost and file be consigned to the record.

    Announced :

    08-06-2015

    (M.P.Singh Pahwa )

    President

     

     

    (Sukhwinder Kaur)

    Member

     

     

    (Jarnail Singh )

    Member