Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No. 97/2018
Manish Aggarwal s/o Sh. Jaikishan Aggarwal,
R/o 393, Kuncha Bulaki Begum,
Dariba Kalan, Delhi-110006 ...Complainant
Versus
Apollo Munich Health Insurance Com. Ltd.
First Floor, 6-7, B.K. Rao Court,
Asaf Ali Road, New Delhi-110002 ...Opposite Party
Date of filing: 04.05.2018
Date of Order: 05 .09.2023
Coram: Shri Inder Jeet Singh, President
Ms. Shahina, Member -Female
Shri Vyas Muni Rai, Member
Vyas Muni Rai
ORDER
1.1. Sh. Manish Aggarwal (in short the ‘complainant’) has filed this complaint against M/s Appolo Munich Health Insurance Co. Ltd. (in short the ‘OP’) under Consumer Protection Act’1986. The complaint is in Hindi language.
1.2. Initially, the complainant purchased medical insurance policy (Easy Health Floater Standard) in the year 2010 vide policy No. 11010/11051/1000083609 from the opposite party and the same has been renewed from time to time and last policy no. 11.100/11051/1000083609-07 with validity period w.e.f. 12.05.2017 to 11.05.2018 and this last policy is the subject matter of the instant complaint.
In the policy, persons insured are complainant himself, Mrs. Jaishree Aggarwal (wife), Baby-Sanchita Aggarwal (daughter) and Master Ashish Aggarwal (son), insured amount is Rs. 4,00,000/- each against premium of Rs. 1,5019.59/ and cumulative bonus of Rs. 2,80,000/-
1.3. The complainant was admitted in the Emergency/Casualty of Tirath Ram Shah Hospital, Delhi on 18.02.2018 for treatment and was discharged on 19.02.2018 from the hospital after treatment. As per the voucher, complainant paid Rs. 14,420/- the expenses incurred on treatment during hospitalization.
1.4. The complainant submitted the claim form in office of OP on 02.04.2018 for the claimed amount of Rs. 14,420/- spent by the complainant on his treatment during the hospitalization w.e.f. 18.02.2018 to 19.02.2018; the OP vide its letter dated 12.04.2018 (which was received by the complainant on 23.04.2018) rejected the claim of the complainant on the ground that as per the submitted documents, the need for hospitalization was not established. Hence, that claim was repudiated u/s VI c XI b of the policy.
1.5. Complainant further pleads that he was not feeling well and consulted the doctor in the hospital, thereafter, it was the decision of the consulting doctor to admit the complainant after conducting different tests. The complainant prays for direction to OP to pay him the claimed amount Rs. 14,420/- along with interest; apart from compensation/damages for mental agony and pain.
1.6. The complaint is accompanied with affidavit, policy dated 12.05.2010, renewal of policy dated 12.05.2017, claim form dated 02.04.2018 duly filled up and OP’s letter dated 12.04.2018 rejecting the claim of the complainant; treatment papers along with vouchers of bills and discharge summary issued by the hospital.
2.1. The OP has filed the reply under the signature of Ms. Deepti Rustagi, Senior Vice-President, Legal and Compliance of the company duly authorized by OP. The complaint is opposed that the same is gross abuse of the process of law; complaint is based on frivolous and baseless facts, there is no cause of action against the OP, complaint is not maintainable, it is barred by limitation, there is suppression of material facts, complaint suffers from non-joinder and mis-joinder of necessary parties; the complaint is barred by section 3 of the Consumer Protection Act, 1986 and same is liable to be tried in the Civil Court of competent jurisdiction and not by way of summary trial. The claims are paid by OP out of common pool of funds belonging to all policy holders of the company and insurer has to check the admissibility of a claim before honouring any such payment as claimed by in the complaint; the complainant suppressed material facts of his previous illness from the OPs. As per proposal form, it is the stand of the OP that “we are under no obligation to accept any proposal for insurance. If we are accept the proposal for insurance, it shall be subject to policy terms & conditions”.
2.2. That the Policy Kit containing the all relevant documents were duly sent and admittedly received by the complainant; OP has also referred that point no. 9 of General Exclusion clause which mentions that “Following is an outline of the ‘general exclusions’ under the policy. For more details on the exclusions and waiting periods please refer the policy wordings before purchasing this policy”. Further, even the renewal notice which is sent to the complainant at the time of renewal of the policy mentioned ‘please retain your policy wordings for current and future use’. Any changes to the policy wordings at the time of renewal, post approval from the regulator will be updated and available on our website www.apollomunichinsurance.com.” However, the complainant never raised any objection with respect to being not supplied policy terms and conditions.
2.3. The OP has cited Section VI C: xi.b. General Exclusions:
“we will not pay for any claim, which is caused by, arising from or in any way attributable to:
xi) Types of treatment, defined illness/conditions/supplies:
b) Conditions for which treatment could have been done on an outpatient basis without any hospitalization.”
2.4. It is also the stand of OP that on 18.2.2018 cashless request was received for patient/complainant Mr. Manish Aggarwal, who was admitted at Tirath Ram Shah Hospital, New Delhi on 18.02.2018, as case of Bronchitis with fever with estimated amount of medical expenses as 45,250/-; the post reviewing of the documents so submitted by the complainant, it was found that certain medical documents had not been provided for, and accordingly query letter was issued to provide ‘detailed line of treatment with admission notes, investigations reports of the patient supporting the diagnosis with the treatment charts and vital charts’.
2.5. OP further mentions that post reviewing the reply so received for the query raised, it was noted that complainant:
- “Admitted for Fever, cough with sputum were from last 1 week, no any emergent symptoms.
- Had No sign of vomiting.
- Was without any major complication and findings I/V antibiotics were started.
- His vitals were normal except mild fever at the time of admission i.e. 100.4.
- All his investigation reports were within normal limits.
- Patient/complainant himself requested for admission as mentioned on admission notes. Relevant portion of the same is pasted in the reply.”
As per the available documents/medical records, indication for the hospitalization cannot be established. Therefore, based on the above facts; claim was rejected vide letter dated 12.04.2018. The complainant/patient himself had requested for admission which is mentioned on admission notes and the treating doctor had never advised complainant as such to get admitted.
2.6. OP has also cited case law which will be dealt at appropriate stage; there is violation of the policy terms & conditions on the part of complainant and no deficiency and unfair trade practices are attracted on the part of OP; the complaint be dismissed with costs as the same is devoid of merit.
3. The complainant has filed rejoinder/replication to the reply of OP and he has denied all the allegations of reply. Rest of the contents of the rejoinder is on the pattern of complaint concluding therein that rejection of claim by OP is not in violation of terms & conditions of the policy; complainant has further submitted that it was on the advice of treating doctor admitting him in the hospital. The complainant was advised by the consulting doctor for treatment by Dr. Amit Gupta, however, complainant requested for treatment under the supervision of Dr. D.K. Singh.
4. The complainant has filed his affidavit of evidence which is on the pattern of complaint duly supported by documents filed with the complaint. OP has also led affidavit of evidence under the signature of Ms. Deepti Rustagi- authorized signatory of OP, the affidavit is on the lines of the facts and features given in the reply.
5. No written arguments were filed either by the complainant or by OP.
6. (Findings): The case was initially reserved for order on the complaint on 04.05.2023, however, while going through the record, it was discovered that earlier an application was filed by OP, which was also replied by the complainant in respect of seeking permission for summoning the treating doctor and it appeared that without pressing the application, the final arguments were advanced. Therefore, it was appropriate to ascertain about pressing/disposal the application, thus notice was issued to both the sides (parties and their counsels) and matter was adjourned for 25.05.2023. It was further adjourned for 29.05.2023 as requested by counsel for OP. On 29.05.2023 the arguments on said application was heard from both the sides and application under reference was disposed off vide order dated 03.06.2023; discussion and decision on this application will be discussed in para-10 of this order. Thereafter, case was listed on 11.07.2023 to refresh the material, but after giving the opportunities none appeared for parties to argue and refresh the matter. Thereafter, the complainant was heard on 31.07.2023 (none appeared for OP) and case was fixed for final order on 05.09.2023.
7. Complainant had health problem and was admitted and was treated in the Tirath Ram Shah Hospital. The complainant submitted required documents with OP for approval of claim of Rs. 14,420/- and his claim was rejected on 12.04.2018 by the OP on the ground mentioned in the rejection letter as mentioned in para no. 1.4 of this order.
8. OP in its reply has taken stereo-type plea that no cause of action has arisen in favour of the complainant and against OP, complaint is not maintainable and barred by limitation, complainant has suppressed material facts about his previous illness; complaint is vague for non-joinder and mis-joinder of necessary parties; the dispute can only be tried by the Civil Court having competent jurisdiction.
9. OP’s objections in para 7 of this order are being taken one by one:
(a) OP has also taken the stand that the complaint is required to be filed and tried by the Civil Court of competent jurisdiction since the adjudication of the mater requires to record and elaborate evidence, oral, documentary, and medical and the same is not possible by way of summary trial. This plea of OP also has no force and is rejected as circumstances of case manifests that there is mala fide omission/ commission on the part of OP.
(b) it is admitted by the parties that complainant visited the hospital on 18.02.2018 on feeling uneasiness and as advised and decided by the consulting/treating doctor, he was admitted in the hospital, complainant paid the bills raised by the hospital and when his claim was rejected by the OP, complainant filed the present complaint. Therefore, cause of action has arisen in favour of the complainant and against OP this objection of OP is rejected.
(c) In the discharge summary dated 30.03.2018, the complainant was diagnosed for acute spasmodic bronchitis with LRTI. In the said discharge summary treating/ attending doctor has recorded that patient Manish Aggarwal, 45 years, male, with no past history of any illness, he was admitted in the hospital on 18.02.2018 with complaints of cough with sputum for last one week, fever for last 3-4 days, breathing difficulty for last 1-2 days, meaning thereby there was no past history of any illness; therefore, the allegation of OP that complainant has suppressed material facts of his previous illness has no force, hence, rejected.
(d) the complaint is barred by limitation, hence not maintainable. This plea of OP is also rejected on the ground that the complainant was admitted in hospital in February-2018, he submitted his claim with OP, in March-2018 which was rejected by OP vide its letter dated 12.04.2018 and complaint has been filed by the complainant on 04.05.2018 which is much within the limitation period as prescribed in the Consumer Protection Act,1986.
(e) The OP has also taken the stand that complaint suffers from non-joinder of necessary parties but has not disclosed as to who how OP is mis-joined is not proved by OP is the necessary party, therefore, this plea of OP is rejected. How OP is mis-joined is not proved by OP.
10. The other ground taken by the OP for rejection of the claim of the complainant is that need for hospitalization was not established and claim was repudiated u/s VI c XI b of the policy. On the point of need for hospitalisation, during the argument on the application filed by OP as mentioned in para no. 6 in this order, it was inquired whether the said hospital/doctor was inquired when the claim was considered by the OP; it was explained that no such enquiry was made. When the complainant visited hospital on 18.02.2018, on the emergency/casualty of the complainant, there is sign by treating doctor on casualty card “↓” and complainant after gathering the information was able to spell out that on page-11 the remarks are to be read as “admit under Dr. Amit Gupta” D. K. Singh” “patient wants admission only “↓” Dr. D.K. Singh”. Therefore, the circumstances are crystal clear that admission was not on insistence of complainant but the treating doctor formed the opinion to admit the complainant for treatment. However, the admission was directed under Dr. Amit Gupta but on the request of the complainant, his request was accepted to the extent to admit complainant under Dr. D. K. Singh. It does not require further elaboration. Therefore, plea of OP that admission was on exclusive insistence of complainant to admit in hospital and want of the need for hospitalization was not established, is erroneous and contrary to record.
11. OP has proved a letter dated 18.02.2018 (Annexure R5) addressed to the Tirath Ram Shah Hospital, Delhi regarding pre-authorization/cashless request, which was rejected on the ground that detailed line of treatment with admission notes, investigation reports of the patient, supporting the diagnosis with the treatment charts to be submitted by the hospital. However, it is evident from the record that on 31.03.20218 Dr. D.K. Singh sent treatment and medication details (Name/dosage and frequency) which at page-8 of his paper book.
12. OP’s plea that Policy Kit containing all relevant documents were duly sent and received by the complainant but complainant never raised objection to any of the terms & conditions of the policy, implying thereby policy terms & conditions were received by him and were also acceptable to him. However, no proof/receipt to this effect has been submitted on record by the OP and the same has also not proved by the OP. The stand of OP that the renewal notice was sent to the complainant will be available on its website It is settled law that insurance contract is of utmost good faith between the insurer and the insured and it is bounden duty of the insurer to send the policy document containing terms & conditions , to insured whether the same is requested by the insured or not. The relevant section/clause of the ‘General Exclusions’ has already been taken in para no. 2.1 of this order. Therefore, it is also settled law that Exclusions Clause is not applicable to the insured when the same was not supplied or spelt to the insured.
Since, there is nothing on record as the plea of OP that if separate terms & conditions supplied or delivered to complainant, as no proof/acknowledgment has been filed by the OP. Therefore, we are of the opinion that the complainant was not made aware about the exclusion clause (s). Since, the complainant was not equipped with the terms & conditions of the policy nor he was made aware of it, thus, the following precedent and case law support the case of complainant:-
(a) Bharat Watch Company (through its partners) Vs. National Insurance Company Limited, civil appeal no. 3912/2019 in SLP (c) No. 25468/2016, it was held that in the absence of appellant being made aware of terms of exclusions, it is not open to the insurer to rely upon exclusionary clauses.
(b) National Insurance Company Limited Vs. Radhey Shyam Balwada & Anr [(II) 2014 CJP 201 NC]- held that insurer has also duty to act in good faith, which obliges him to enter into contract without concealing material fact like exclusion clauses. Further, an insured is not bound by the exclusions clauses of policy, if the same is not explained to him.
13. OP in its reply has referred case law (a) Authority under Yeshashwini Wima Yojna Vs. Mumtaz Begum-RP 1173/2007; (b) General Assurance Society Ltd. Vs. Chandumull Jain and Another, reported in (1966) 3 SCR 500; (c) Oriental Insurance Co. Ltd. Vs. Sony Cheriyam AIR 1999 SC 3252-; (d) Appeal No.6277 of 2004 titled “United India Insurance Co. Ltd. Vs. Harchand Rai Chandan Lal” decided on 24.09.2004. Ratio of the above case law cited by OP are not applicable in the present case as OP’s citation are with regard to interpretation of contract and documents related to a contract of insurance by the court, insurance policy between the insurer and the insured reiterates contract between the parties. The insured claimed in any way more than what is covered by the insurance policy and parties are bound by the terms & conditions contract and a court or authority or Forum cannot re-write such a contract.
Therefore, since the complainant was not made aware about the exclusions clauses, there is no violation of terms & conditions on his part.
14. It is for the consulting and treating doctor to finalize whether or not the patient requires hospitalization; it is admitted by the OP that cashless facility was denied vide letter dated 18.02.2018. Thereafter, complainant applied for reimbursement, which was also repudiated vide letter dated 12.04.2018. OP’s plea that complainant did not submit some documents (though it remains unproved) is only device to deny the valid claim of the complainant under health insurance policy. In addition on request of the OP, Dr. D.K. Singh-(the treating doctor) also supplied medical documents on 31.08.2018 as requested by OP by letter addressed to hospital. All the treatment papers and laboratory tests reports duly attested by Dr. D.K. Singh were submitted by the complainant along with his complaint.
15. In view of the aforesaid discussion, complainant has proved his case of non-payment/reimbursement of valid medical claim covered under insurance contract, which is deficiency of service and unfair trade practice on the part of OP. Therefore, we hold the complainant is entitled for reimbursement of mediclaim of Rs. 14,420/-; OP is liable for the deficiency of service and unfair trade practice.
16. Since deficiency of service stands proved against OP; OP is held liable to pay Rs. 14,420/- with interest to the complainant being the claimed amount spent on his treatment and paid to the hospital, however, the rate of interest has not been mentioned by the complainant. Since, the complainant was deprived of his money, he has paid the medical expenses out of his pocket, therefore, interest @ 8% pa is decided to meet the ends of justice.
17. The complainant also seeks damages/compensation for mental pain and agony and it should be commensurate to the situation. The complainant paid the medical bills amounting to Rs. 14,420/- in the year 2018 and has been deprived of his money since then and he was harassed by the OP as his claim was not paid. Thus, it would justify both the end to quantify damages of Rs. 10,000/- and accordingly it is awarded.
18. Considering the facts and circumstances, conclusion is drawn and OP is directed to pay the complainant Rs. 14,420/- the amount spent on his treatment along with 8% p.a. interest from the date of filing of complaint till realization, Rs. 10,000/- damages/compensation to be paid by OP to the complainant.
19. The aforesaid amounts shall be paid by OP to the complainant within 30 days from the receipt of this order, failing which the amount of Rs. 14,420/- shall be payable with interest of 9% p.a. instead of 8% p.a.
20. Announced on this 5th September, 2023.
21. Copy of this order be sent/provided forthwith to the parties free of cost as per rules for necessary compliance.
[Vyas Muni Rai] [ Shahina] [Inder Jeet Singh]
Member Member (Female) President
