District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.148/2020.
Date of Institution:17.03.2020.
Date of Order: 29.10.2024
Sanjeev Kumar son of Shri Gore Lal R/o House No. 2744, Gali No.2, Ward No.5, Near Saran School road, Jawahar Colony, NIT, Faridabad.
…….Complainant……..
Versus
1. Apollo Munich Health Insurance Co. Ltd., 2nd & 3rd floor, ILABS Centre, Plot NO. 404-405, Udyog Vihar,Phase-3, Gurugram through its Branch Manager/Manager.
2. Oriental Insurance Co. Ltd., Ist floor, Jain Bhawan, 12, Shaheed Bhagat Singh Marg, Gole Market, Delhi – 110 001 through its Branch Manager/Manager.
3. National Insurance co. Ltd., Ist floor, Palika Bhawan, Sector-13, Ring Road, R.K.Puram, New Delhi – 110 066 through its Branch Manager/Manager.
4. Fortis Escorts Hospital, Neelam Bata Road, Faridabad through its authorized person.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma………..Member
Indira Bhadana………….Member.
PRESENT: Shri S.S.Sharma, counsel for the Complainant.
Sh. Rakesh Dabaas, counsel for opposite party No.1.
Shri Jatinder Singh, counsel for opposite party No.2.
Shri Ajay Kumar Sharma, counsel for opposite party No.3.
Shri Rajesh Khanna, counsel for opposite party No.4.
ORDER:
The facts in brief of the complaint are that the complainant was holder of happy family floater policy of opposite party No.2 vide policy No. 215600/48/2010/4407 valid from 23.02.2010 to 22.2.2011 and the same was renewed next year i.e. 22.02.20212. The complainant shifted to the Insurance Company National Insurance i.e opposite party No.3 and took hospitalization benefit policy premier mediclaim form opposite party No.3 vide policy NO. 351800/48/11/850002481 valid from 18.01.2012 to 17.01.2013 and same was renewed for the year 2014-15 and finally on 17.01.2016. During the period of above said insurance neither the complainant nor his dependants used these policies for any type of ailment and lastly the complainant shifted/ported the insurance policy to optima Restored policy of opposite party vide policy No. 110100/11121/AA00342550 valid from 18.01.2016 to 17.01.2017 and same policy was renewed form year to year valid upto17.01.2020. Wife of the complainant Mrs. Jyoti got admitted on 8th July 2019 in Fortis Escorts Hospital, Neelam Bata Road, Faridabad with some problem in the stomach where on admission she was diagnosed with Ventral Hernia with congitenal myopathy and they were operated upon by Ventral Hernia Plasty procedure on 09.07.2019. The complainant had taken pre approval from opposite party No.1. The opposite party No.1 however denied cashless policy vide its letter dated 12.07.2019 alleging in therein that there was an non discloser of disease/congitenal myopathy before policy inception. The treating doctor Dr. ManuShanker (M.S. DNB (General Surgery) vide its letter dated 13.07.2019 had categorically mentioned that the present ventral hernia for which Mrs. Jyoti was treated was not linked or caused due the congiternal myopathy. It was submitted that Ventral hernia could be caused by so many reason. Even on 12.07.2019 Dr. Prathu gave a separate note stating that therein that Mr. Jyoti was being operated for Ventral Hernia and her hernia was not related to congitenal myopathy and no treatment had been given for the same. That was why the hospital had been impleaded as opposite party No.4. The complainant after denied the cashless facility by opposite party No.1 paid a sum of Rs.1,17,706/- by arranging funds from relatives friends and got financing an amount Rs.45,000/- form its hospital itself. After discharge of Mrs. Jyoti the complainant submitted claim form alongwith all original treatment papers claiming an amount of Rs.1,17,706/- on 22.07.2019 which was duly acknowledged by opposite party No.1 at Gurugram office and surprisingly on 24.07.2019, the complainant received an email form opposite party No.1 on 22.07.2019 where in a notice of termination u/s IV of the policy document in which the reason for termination was given congiternal myopathy and bilaternal plantar facilities and again on 24.07.2019 the complainant again received a letter under section 7 of the policy documents where the reason for termination was mentioned pepilary thyroid carcinoma since 2015. Mrs. Jyoti was not suffering form pepilary thyroid carcinoma.The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) pay an amount of Rs.1,17,706/- as medical expenses incurred of the treatment.
b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment .
c) withdraw the notice of termination of the policy and order for its continuation if the complainant desire.
d) cost or any other relief which this Hon’ble Forum may deems fit and proper may also be awarded in favour of the complainant.
2. Opposite party No.1 put in appearance through counsel and filed written statement wherein Opposite party No.1 refuted claim of the complainant and submitted that the complainant had signed and submitted the application/proposal form bearing NO. 6101327354. The date of the application form was 23.12.2015. On the basis of the information and the contents of the proposal form submitted by the proposer and believing the above said declaration, information and details provided by the proposer including the medical history in the PF to be true, correct and complete in all respect, giving due credence to the under writing norms of opposite party company, a policy No. 110100/11121/Aa00342550 was issued for sum assured opted as per PF, to the complainant for the period between 18.01.2016 to 17.01.2017 and the same was renewed form time to time. On 05.07.2019 cashless was received form Fortis Escorts Hospital Faridabad for patient Jyoti Singh who planned for admission for surgery of Ventral Hernia with Congenital Myopathy, Post Spinal headache with date of admission 08.07.2019 with estimated cost of Rs.1,57,309/-. After reviewing the documents initial approval of Rs.1,00,000/- given subject to below conditions:
i) the hospital bill was estimated to be higher than the guarantee of payment, a request letter for additional amount needs to be sent to them, if no further guarantee was available, the hospital must collect the excess amount directly from the beneficiary at the time of admission/prior to discharge from the hospital, as per hospital rules and regulations.
ii) They would not be liable for payment to the hospital in the event of the facts presented by the hospital/insured during the preauthorization were found to be incorrect/revised.
iii) the claim settlement would be as per the Tariff Discounts contracted in the network agreement.
iv) Please ensure to collect the charges pertaining to non-payable items as per the list shared in provider guide book”Parichay”.
v) Please ensure to collect Copayment Rs.0 from the member.
Thereafter the complainant/proposer submitted his/her claim for reimbursement on 22.07.2019, with date of admission 08.07.2019 and date of discharge 12.07.2019 and diagnosis for Ventral Hernia with congenital Myopathy, Post Spinal Headache with final claimed amount Rs.1,17,706/- and after reviewing the same it was observed that cashless request was already rejected due to non-disclosure of medical history details of congenital myopathy7 and bilateral plantar fasciitis since 13.03.2014 i.e before policy inception which was not disclosed by the complainant’s wife at time of taking policy with opposite party company. Hence, the claim was rejected and policy was also cancelled by the answering opposite party company as per policy terms and conditions. Opposite party No.1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Opposite party No.2 put in appearance through counsel and filed written statement wherein Opposite party No.2 refuted claim of the complainant and submitted that the present complaint was not legally maintainable against the answering opposite party No.2 M/s. Oriental Insurance company ltd., in any manner, whatsoever as the wife of the complainant namely Ms. Jyoti was being shown to be got admitted in Fortis Escorts Hospital on 08.07.2019 diagnosed to be suffering from Ventral hernia with Congiternal Myopathy for which they were operated upon on 09.07.2019, for which the opposite party No.2 denied cashless facility. The complainant had no cause of action to maintain or sustain the present complaint against the answering opposite party No.2 the Oriental Insurance Company Ltd., From the perusal of the contents of the complaint and form the perusal of the Happy Family Floater policy No. 215600/48/2010/4407 and the insurance policy No. 215600/48/2011/4332 were issued covering the insurance risk for the period 23.02.2010 to 22.02.2011 and thereafter for the period 23.02.2011 to 22.02.2012, respectively whereas the alleged insurance claim dispute was for the ailment and hospitalization period of 08.07.2019 and 09.07.2019, when the complainant was having the insurance policy with the opposite party No.1 for the period 23.01.2018 to 22.01.2019. As such, the answering opposite party No.2 had nothing to do with the complainant and the hospitalization and treatment of patient Jyoti, the wife of the complainant, as such requires to be dismissed qua the answering opposite party No.2. Opposite party No.2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
4. Opposite party No.3 put in appearance through counsel and filed written statement wherein Opposite party No.3 refuted claim of the complainant and submitted that the answering opposite party had no concern because at the time of wife of complainant was admitted in hospital she was not insured with the answering opposite party and the opposite party No.1 had already repudiated the claim of the complainant and declined to pay the claimed amount. Opposite party No.3 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
5. Opposite party No.4 put in appearance through counsel and filed written statement wherein Opposite party No.4 refuted claim of the complainant and submitted that the wife of the complainant was admitted in opposite party No.4 hospital on 8th July 2019 for treatment. Considering the nature of complication in the health of the complainant’s wife she was admitted in the opposite party No.4 for necessary investigation and treatment. It was submitted that after in detail investigation and treatment of the complainant’s wife she was discharged from the answering opposite party hospital. Opposite party No.4 had raised the bill for a total amount of Rs.1,25,105.64/- upon the complainant and the same was paid by the complainant. The dispute in the present matter was alleged only opposite parties Nos.1,2 & 3 regarding not release of mediclaim insurance amount. The complainant had not stated a single word against the answering opposite party proving any kind of negligence in the treatment rendered to his wife. It was submitted that there was no role of the answering opposite party in releasing the mediclaim amount to the insurer and same had to be done by opposite parties Nos.1 to 3 only. It was submitted that the agreement was entered between the complainant and the opposite parties Nos.1 to 3, answering opposite party No.4 was not a party to said agreement. Hence, the entire dispute was between the complainant and the opposite parties Nos.1 to 3. Opposite party No.4 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
6. The parties led evidence in support of their respective versions.
7. We have heard learned counsel for the parties and have gone through the record on the file.
8. In this case the complaint was filed by the complainant against opposite parties– Apollo Munich Health Insurance Co. Ltd. & Ors.with the prayer to: a) pay an amount of Rs.1,17,706/- as medical expenses incurred of the treatment. b)pay Rs.1,00,000/- as compensation for causing mental agony and harassment . c)withdraw the notice of termination of the policy and order for its continuation if the complainant desire. d) cost or any other relief which this Hon’ble Forum may deems fit and proper may also be awarded in favour of the complainant.
To establish his case, the complainant has led in his evidence Ex.CW1/A – affidavit of Sanjeev Kumar, Ex.C-1 – insurance policy valid from 23.02.2010 to 22.02.2011, Ex.C-2 – insurance policy valid from 23.02.2011 to 22.02.2012, Ex.C-3 – insurance policy valid from 18.1.2012 to 17.01.2013, Ex.C-4 – insurance policy valid from 18.01.2013 to 17.01.2014, Ex.C-5 – insurance policy valid from 18.01.2014 to 17.01.2015, Ex.C-6 – insurance policy 18.01.2015 to 17.01.2016, Ex.C-8 – renewal of Optima Restore Insurance Policy, for the period 23.01.2017 to 22.01.2018, Ex.C-9 – insurance policy 23.01.2018 to 22.01.2019, Ex.C-10 – Renewal of Optima Restore Insurance Policy valid from 23.01.2019 to 22.01.2020, Ex.C-11 – Authorization letter, Ex.C-12 – Discharge summary,, Ex.C-13 – Inpatient Detail Bill, Ex.C-14 – Denial of cashless service, Ex.C-15 – letter dated 22.07.2019 regarding notice for termination, Ex.C-16 – letter dated 24.07.2019 regarding notice for termination,Ex.C-17 – certificate of Fortis Escorts Hospital, Ex.C-18 – certificate of Dr. Manu Shankar, Ex.C-19 – Certificate of Dr. Manu Shankar, Ex.C-20 – rejection letter, Ex.C-21 – rejection letter dated 29.08.2019.
On the other hand counsel for the opposite party No.1 strongly agitated and opposed. As per the evidence of the opposite party No.1 Ex.RW1/A – affidavit of Shweta Pokhiryal , Senior Manager (Legal_ HDFC ERGO General Insurance Co. Ltd. and now has been merged in HDFC ERGO General Insurance Co. Ltd., Zonal Office, 5th floor, Tower 1, Stellar IT Park, C-25, Sector-62, Noida, Ex.R-1 - proposal form,, Ex.R-2(colly) - Optima Restore Policy Schedule valid from 18.01.2016 to 17.01.2017, Ex.R-3(colly) – Pre-Authorization Form, Ex.R-4 – Discharge summary, Ex.R-5(colly) – rejection letter dated 29.08.2019.
As per evidence of opposite party No.2, Ex.RW2/A – affidavit of Ramesh Kumar, Senior Divisional Manager, M/s. Oriental Insurance Company Limited, 5B/4BP, Railway Road, NIT, Faridabad,
As per evidence of opposite party No.3, Ex.R-1 is the affidavit of Shri Shharat Kashyap, National Insurance Co. Ltd..
Shri Rajesh Khanna, counsel for opposite party No.4 has suffered a statement that W.S. filed by opposite party No.4 may be read as such evidence on behalf of opposite party No.4 & closed their evidence on their behalf vide order dated 17.04.2023.
9. In this case, the complaint was filed by the complainant with the prayer to opposite party No.1 to pay an amount of Rs.1,17,706/- as medical expenses incurred of the treatment. To prove his case, the complainant led in his evidence Ex.C-1 to Ex.C-21. On the other hand, opposite party No.1 led in their evidence Ex.R-1 to R-5.
10. As per certificate vide Ex.C-18, the treating doctor Dr. Manu Shanker (M.S. DNB (General Surgery) vide its letter dated 13.07.2019 has categorically mentioned that the present ventral Hernia for which Mrs. Jyoti is treated is not linked or caused due the Congitenal myopathy. It is pertinent to mention here that Ventral Hernia can be caused by so many reason. As per Ex.C-17, Even on 12.07.2019 Dr. Prathu gave a separate note stating therein that Ms. Jyoti is being operated for Ventral Hernia and here herenia is not related to Congitenal Myopathy and no treatment has been given for the same. Opposite party No.1 repudiated the claim of the complainant on the ground that “the medical history details of congenital myopathy and bilateral plantar fasciitis since 13.3.2014 is before policy inception is not revealed while taking the policy in the proposal form. Hence, the claim is repudiated due to non disclose and concealment of facts under section VI J of policy terms and conditions.
11. Keeping in view of the above submissions as well as the evidence led by the parties, the Commission is of the opinion that as per certificate vide Ex.C-18, the treating doctor Dr. Manu Shanker (M.S. DNB (General Surgery) vide its letter dated 13.07.2019 has categorically mentioned that the present ventral Hernia for which Mrs. Jyoti is treated is not linked or caused due the Congitenal myopathy. Hence, the repudiation done by the opposite party No.1 is not justified. Resultantly, the complaint is allowed.
12. Opposite party No.1 is directed to pay an amount of Rs.1,17,706/- alongwith the interest @ 6% p.a. from the date of filing of complaint till its realization. Opposite party is also directed to pay Rs.3300/- as compensation for causing mental agony & harassment alongwith Rs.2200/- as litigation expenses to the complainant. Compliance of this order be made within 30 days from the date of receipt of copy of this order. Copy of this order be sent to the parties concerned free of costs. File be consigned to the record room.
Announced on: 29.10.2024 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
