Haryana

Kurukshetra

225/2018

Gurpreet Singh - Complainant(s)

Versus

Appolo Health Ins - Opp.Party(s)

S.S.Sharma

18 Feb 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION  KURUKSHETRA.

 

Consumer Complaint No.225 of 2018

Date of Instt.:16.10.2018.

Date of Decision:18.02.2021.

 

Gurpreet Singh son of Hartej Singh resident of village Mehra P.O.Bakali Tehsil Ladwa, District Kurukshetra.                             

                                                              …….Complainant.       

                                                   Versus

 

1.Apollo Munich Health Insurance 1^st Floor, SCF-19, Sector-14, Gurgaon 122001 (Haryana) through its Manager.

 

2. Canara Bank, Branch village Mehra District Kurukshetra through its Manager.                                                                                                                      ….…Opposite parties.

 

                Complaint under Section 12 of Consumer Protection Act.

 

Before        Smt. Neelam Kashyap, President.    

                   Ms. Neelam, Member. 

                   Shri Issam Singh Sagwal, Member.                           

 

Present:      Sh.S.S.Sharma counsel for the complainant.

                   Sh.Mohit Tayal Advocate for the OP No.1.

                   Sh.Y.R.Bansal Advocate for OP No.2.

 ORDER

                   This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by the complainant Gurpreet Singh  against Apollo Munich Health Insurance  etc., the opposite parties.

 

2.                In brief, the case of the complainant is that the complainant  had purchased  health insurance policy from OP No.2 vide insurance policy No.120100/12586/2017/A007873/PE00708751  valid from 8.11.2017 to 7.11.2018 and the sum assured under the said policy was Rs.1,00,000/-. It is further averred that the complainant fell ill in the month of March 2018 and went to Waryam Singh Hospital, Jagadhri Road, Yamunanagar for his treatment where he was got admitted as per directions of Dr.Rupinder Singh from 5.03.2018 to 11.03.2018. The complainant spent Rs.45,000/- on his treatment, out of which Rs.12200/- on medicine charges, admission fee of Rs.500/- and Rs.17500/- for seven days,  Nursing Charges Rs.3500/- Doctor visit charges Rs.3500/- for seven days, misc. Rs.10,000/- including transportation etc. It is averred that thereafter the treatment, the complainant approached the OPs and submitted his claim and as per their instructions  submitted all the documents as demanded by the officials of the OPs through courier services but the  OPs   failed to give the claim of the complainant without any reason or cause and kept postponing the matter on one pretext or the other which amounts to deficiency in services on the part of the OPs.  Thus, the complainant alleging deficiency in services on the part of the OPs, has filed the present complaint and prayed that the OPs be directed to  pay the claim amount of Rs.45,000/- alongwith compensation for the mental harassment caused to him and the litigation expenses.

 

3.                Notice of the complaint was given to the OPs. OP No.1 filed its written statement disputing the claim of the complainant.  It is submitted that the complainant submitted the  claim for reimbursement with diagnosis of Viral hepatitis  “A” Acute Gastroenteritis with mod dehydration with date of admission 5.03.2018 and date of discharge 11.03.2018.  The complainant with the intention of mislead this Commission has concealed the fact that answering OPs have writing letters ( dated 16.4.2018 and 9.05.2018)  to complainant to provide relevant documents to enable it to consider his claim. However, complainant had not provided required documents relating to queries which has compelled answering OP to close /reject because the complainant failed to supply all investigation, treatment and follow up records pertaining to hepatitis A since first diagnosis, all payment receipts in original for the bill, consolidated final bill with breakup details in original, on hospital letterhead and medical reports of all investigations done during current hospitalization etc. All other allegations made in the complaint have been denied specifically and  preliminary objections regarding  pre-mature complaint, maintainability, mis-joinder and non joinder of the complaint etc.

 

4.                The OP No.2 filed its separate written statement disputing the claim of the complainant. Purchase of the insurance policy by the complainant has been admitted by the OP No.1 but rest of the contents of the complaint have been denied for want of knowledge. It is submitted that the complainant never approached the OP No.2 as the claim was to be paid by the OP No.1. All other allegations made in the complaint have been denied and preliminary objections regarding maintainability, locus standi, estoppels, mis joinder and non-joinder of the parties and that of jurisdiction have been raised.

 

5.                The complainant in support of his complaint has filed affidavit Ex.CW1/A and tendered documents Ex.C-1 to Ex.C-13 and closed his evidence.

 

6.                OP No.2 in support of  its case has filed affidavit Ex.CW1/A and tendered documents Annexure-A,  Annexure  R-1 to Annexure R-7 and closed its evidence.

 

7.                The learned counsel for the complainant has argued that the complainant purchased  health insurance policy from OP No.2 vide insurance policy No.120100/12586/2017/A007873/PE00708751  valid from 8.11.2017 to 7.11.2018 and the sum assured under the said policy was Rs.1,00,000/-. It argued  that the complainant fell ill in the month of March 2018 and went to Waryam Singh Hospital, Jagadhri Road, Yamunanagar for his treatment where he was got admitted as per directions of Dr.Rupinder Singh from 5.03.2018 to 11.03.2018. The complainant spent Rs.45,000/- on his treatment but his claim has not been paid which is deficiency in services on the part of the OPs. The learned counsel for the complainant has  given the authority National Insurance Co.Limited Vs. Sandeep and others 2017(1) RCR(Civil) 621.

 

8.                On the other hand, the learned counsel for the OPs  while reiterating the submissions made in the  written reply has argued that the complainant has  that the complainant submitted the  claim for reimbursement with diagnosis of Viral hepatitis  “A” Acute Gastroenteritis with mod dehydration with date of admission 5.03.2018 and date of discharge 11.03.2018.  It is argued that the  complainant with the intention of mislead this Commission has concealed the fact that answering OPs have writing letters ( dated 16.4.2018 and 9.05.2018)  to complainant to provide relevant documents to enable it to consider his claim. It is further argued that the  complainant had not provided required documents relating to queries which has compelled answering OP to close /reject because the complainant failed to supply all investigation, treatment and follow up records pertaining to hepatitis A since first diagnosis, all payment receipts in original for the bill, consolidated final bill with breakup details in original, on hospital letterhead and medical reports of all investigations done during current hospitalization etc. Thus, it is argued that there is no deficiency in services on the part of the OPs.

 

9.                After hearing the learned counsel for the parties, we are of the view that there is no dispute as to the issuance of the insurance policy to the complainant and his treatment. The OPs have wrongly denied the claim of the complainant.   Perusal of the file shows that  Ex.C-2 is the detailed discharge summary wherein history and clinical findings and investigation report is mentioned. Ex.C-3 to Ex.C-10 are copies of bills showing Rs.25000/- paid to the doctor for hospital charges and medicine bills. In our view when various bills and receipts are on the file, then there is no need for consolidated bill because medicines have been purchased between 5.3.2018 to 10.03.2018 and the complainant is entitled for reimbursement of the said amount spent by him. Denial of claim on technical grounds is not tenable in the eyes of law. The total of Ex.C-3 to Ex.C-10 comes to Rs.37109/- and as such the complainant is entitled to reimbursement for the same. The  OP no.1 has failed to pay the said  claim amount of Rs.37109/- to the complainant which amounts to deficiency on the part of the OP No.1. As the OP No.1 has wrongly with held the said claim amount of the complainant, therefore, the complainant is entitled for interest @ 6 % per annum on the claim amount also besides compensation for the mental harassment and agony caused to him and the litigation expenses. No allegations have been leveled against OP No.2 in the complaint, therefore, no deficiency in services is made out against OP No.2.

 

           In National Insurance Company’s case (Supra):  it is clearly mentioned that  “Most of the times, as it has been experienced in the recent past, even the genuine claim would be rejected on one or the other technical  or flimsy ground, giving rise to such kind of avoidable litigation.”  On relying upon the citation, we accept the present complaint.

 

10.              As a discussion of our above findings, we accept the present complaint and direct the OP No.1 to make the payment of Rs.37109/- to the complainant alongwith interest @ 6% per annum from the date of filing of the present complaint i.e. 16.10.2018 till its actual realization. The complainant shall also be entitled for a sum of Rs.5000/- as compensation for the mental harassment and agony caused to him together with a sum of Rs.5000/- as litigation expenses. The OP No.1  is   further directed to make the compliance of this order within a  period of  45 days from the date of preparation of certified copy of this order, failing which, the complainant will be at liberty to initiate proceedings under Section 25/27 of the Act against the OPs. The complaint qua OP No.2 stands dismissed.  Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the record-room, after due compliance.

 

Announced in open commission:

Dt.:18.02.2021                                                     (Neelam Kashyap)

                                                                                  President.

 

 

(Issam Singh Sagwal),              (Neelam)         

 Member                                     Member.