Haryana

Gurgaon

CC/366/2012

Laxmi - Complainant(s)

Versus

Appollo Munich Ins etc - Opp.Party(s)

18 May 2016

ORDER

                                        DISTRICT   CONSUMER   DISPUTES   REDRESSAL FORUM, GURGAON-122001

                                                                                                            Consumer Complaint No: 366 of 2012                                                                                                                       Date of Institution: 19.09.2012/04.10.2012                                                                                                                                          Date of Decision: 18.05.2016

Laxmi w/o Shri Pratap Singh R/o H.No.2026, Aadarsh Nagar, Mohna Road, near Kaushik Medical Store, Ballabgarh, District Faridabad.

                                                                                                                                                                                                                        ……Complainant.

                                                Versus

M/s Apollo Munich Health Insurance Company Ltd, 10th Floor, Tower-B, Building No.10, DLF Cyber City, DLF City, Phase-II, Gurgaon through its Manager.

 

Ashok Gupta agent M/s Apollo Munich Health Insurance.

                                                                                              ..Opposite parties

                                                                                               

Complaint under Sections 12 & 14 of Consumer Protection Act,1986                                                                  

 

BEFORE:     SHRI SUBHASH GOYAL, PRESIDENT

SMT JYOTI SIWACH, MEMBER

                   SH.SURENDER SINGH BALYAN, MEMBER.

 

Present:        Ms. Laxmi complainant in person

                    Shri Shakunt Saumitra, Adv for OP-1

                    Shri Ashok Gupta, OP-2 in person.

 

ORDER       SUBHASH GOYAL, PRESIDENT.

The case of the complainant, in brief, is that she had been obtaining the Mediclaim insurance policy from Oriental Insurance Company for the last more than five years and the last policy was issued by Oriental Insurance Company bearing Policy No.48/2011/5919 which was valid till 29th Oct, 2011. The agent of OP-1 i.e. OP-2 approached the complainant and showed notification issued by Government of India by which a policy holder can change the service provider without any break and with full benefits of previous policy. Thus, being lured by OP-2, the complainant had taken policy from OP-1 bearing No.110103/11051/1000248753 which was valid till 19.10.2012. However, during the subsistence of the insurance policy the complainant was admitted in Zenith Hospital, Mohna Road, Ballabgarh on 11.02.2012 for treatment where she remained admitted till 12.02.2012 and incurred a sum of Rs.24,608/- on her treatment. The complainant submitted the bills along with requisite documents but opposite parties failed to reimburse the claim and thus, the OPs were deficient in providing services to the complainant. The complainant prayed that the opposite parties be directed to reimburse the claim of Rs.24,608/- with interest. She also sought compensation of Rs.50,000/- for harassment and mental agony and litigation expenses to the tune of Rs.11000/-.

2                 OP-1 in it written reply has alleged that the claim of the complainant was received on16.02.2013 through claim form related to treatment of Deviated Nasal Septum along with Bilateral Sinusitis with surgical procedure fee and S/L Septoplasty respectively. Under section 6-c-ii of the policy issued in this case, surgery on sinuses and surgery for Nasal Septum Deviation is specifically excluded from coverage for two years from the start of the policy and in this case the policy of the complainant started on 20.10.2011 and the claim related to treatment between 11.02.2012 to 12.02.2012. As such the claim of the complainant was rightly repudiated vide letter dated 25.02.2012.

3                 We have heard the parties and have perused the record available on file.

4                 Therefore, from the facts and circumstances of the case, evidence on the file and the arguments advanced by the parties, it emerges that the complainant has filed the present complaint against the OPs alleging deficiency in service on their part on the ground that the complainant had been obtaining medi-claim policy for the last more than five years from Oriental Insurance Co. and as per new direction the complainant was entitled to change the insurance company i.e. service provider  and consequently, the complainant obtained mediclaim from OP-1 which was valid w.e.f. 20.10.2011 till 19.10.2012 and during the subsistence of the said policy on 11.02.2012 the complainant was admitted in Zenith Hospital, Mohna Road, Ballabgarhand  and remained admitted w.e.f. 11.02.2012 to 12.02.2012 and incurred expenses to the tune of Rs.24,608/-. The complainant submitted all the documents for reimbursement of mediclaim but in vain. The complainant also sent legal notice and thereafter has filed the present complaint.

5                 However, as per the contention of the OP, there was no deficiency in service on the part of the OP and the claim of the complainant has not been reimbursed in view of Exclusion Clause 6-c-ii as the waiting period of two years has not elapsed from the inception of the policy and the claim had arisen in the first year and thus it was rightly repudiated.

6                 However, after going through the facts and circumstances of the case and the evidence placed no file it emerge that section 6 which belongs to Exclusion Clause and Sub Section c under which the claim has been repudiated it emerge that  that there was waiting period of two years with regard to the claim on account of disease/operation and claim was liable to be reimbursed only during third year policy. However, there is Exception Clause 6(c)(ii) which reads as under:-

“The illnesses and treatments 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 continuously and without any break:

Illnesses: arthritis if non infective…………………….
Treatments: benign ear, nose and throat (ENT) disorders and surgeries (including but not limited to adenoidectomy, ………………………………….; surgery on tonsils and sinuses; surgery for nasal septum deviation.

However, a waiting period of two years will not apply if the Insured Person was insured continuously and without interruption for at least 2 years under any other Indian insurer’s individual health insurance policy for the reimbursement of medical costs for inpatient treatment in a hospital and he establishes to Our satisfaction that he was unaware of and had not taken any advice or medication for such illness or treatment.

 

7                 After going through the said above Exclusion Clause waiting period of two years would not be applicable if the insured had been taking the insurance health policy continuously without any interruption for at least two years under any other Indian Insurer’s individual health insurance policy therefore, in view of the Exclusion Clause 6-c-ii it emerges that if the waiting period  of two years has elapsed under any insurance policy then the claim is liable to be reimbursed. In the instant case the complainant has placed on file the following insurance policies showing continuity :

Name of the Insurance Company

Policy Number

Period of Insurance

 

 

 

National Insurance Co.Ltd

260600/46/05/8500000830

27.10.2005 to 26.10.2006

National Insurance Co.Ltd

260600/46/06/8500000587

27.10.2006 to 26.10.2007

United India Ins.Co.Ltd

221600/48/07/41/00002190

27.10.2007 to 26.10.2008

United India Ins.Co.Ltd

221600/48/08/41/00002891

27.10.2008 to 26.10.2009

Bharti Axa General Ins.

Control No.:lhpl/2005/0594

27.10.2009 to 26.10.2010

Oriental Insurance Co. Ltd

48/2011/5919

30.10.2010 to 29.10.2011

 

In view of above the Exclusion Clause 6-c-ii  is not applicable to the facts and circumstances of the present case and as such the repudiation of the claim by the opposite party no.1 tantamounts to deficiency in service.

8                 Therefore, we allow the present complaint and direct the opposite party no.1 to reimburse the medi-claim of the complainant to the tune of Rs.24,608/- as per terms of the insurance policy  along with interest @ 9 % p.a. from the date of filing of the present complaint i.e. 19.09.2012 till realization.  The complainant is also entitled to compensation for harassment and mental agony as well as litigation expenses to the tune of Rs.10,000/-. The OP-1 shall make the compliance of the order within 30 days from the date of receipt of the copy of this order. The parties be communicated of the order accordingly and the file be consigned to the records after due compliance.

 

Announced                                                                                                                                           (Subhash Goyal)

18.05.2016                                                                                                                                              President,

                                                                                                                                                       District Consumer Disputes

                                                                                                                                                         Redressal Forum, Gurgaon

 

(Jyoti Siwach)        (Surender Singh Balyan)

Member                 Member