BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.
Consumer Complaint No. 233 of 2015
Date of Institution: 19.04.2015
Date of Decision: 06.06.2016
Mr.Nitin Aggarwal son of Sh.Anil Aggarwal, resident of 349, Basant Avenue, Amritsar.
Complainant
Versus
Apollo Munich Health Insurance Company Limited, through its Chairman/ Managing Director/ Principle Officer, service through its Branch Office at SCO 4, 4th Floor, District Shopping Complex, Ranjit Avenue Amritsar through its Branch Manager.
Opposite Party
Complaint under section 12 & 13 of the Consumer Protection Act, 1986 as amended upto date.
Present: For the Complainant: Sh.Deepinder Singh, Advocate
For the Opposite Party: Sh.Vimal Mehta, Advocate
Coram
Sh.S.S.Panesar, President
Ms.Kulwant Kaur Bajwa, Member
Mr.Anoop Sharma, Member
Order dictated by:
Sh.S.S. Panesar, President.
1. Sh.Nitin Aggarwal has brought the instant complaint under section 12 & 13 of the Consumer Protection Act, 1986 on the allegations that he has been taking the medi claim policy for himself and his wife Smt.Megha Aggarwal and child from the Opposite Party and lastly took the policy covering risk period from 31.3.2014 to 1.4.2015 by paying the premium amount of Rs.6488.79 paisa bearing policy No. 180200/11051/1000379918-01, copy of policy is annexed. The complainant is consumer as provided under the Act and is competent to invoke the jurisdiction of this Forum. The complainant unfortunately fell ill while having diagnosis of Myathenia Gravis and was to be hospitalized for the period 14.8.2014 to 20.8.2014 at Medanta, The Medicity Gurgaon, Haryana, copy of hospital card is annexed. Hospitalisation as well as medical expenses for the treatment of the complainant came to be Rs.55,130/- including the medication while the complainant was insured for the amount of Rs.3 lacs. The complainant filed the claim with the Opposite Party and the Opposite Party repudiated his genuine claim vide its letter dated 27.10.2014 on frivolous grounds that the admission is for investigation and evaluation of the ailment, which are not sustainable in the eyes of law. The Opposite Party failed to go through the medical treatment taken by the complainant and the status of the insurance obtained by the complainant. Said repudiation of the genuine claim of the complainant without ascertaining the correct facts by the Opposite Party, is the arbitrary act of the Opposite Party. It is further pertinent to mention over here that no such policy condition as mentioned in the repudiation status is communicated to the complainant ever by the Opposite Party. The complainant has complied with all the formalities as required by the Opposite Party from time to time for the settlement of the genuine claim, but the Opposite Party has repudiated the claim of the complainant on frivolous grounds. The complainant has prayed for the following reliefs vide instant complaint.
a) Opposite Party be directed to pay the amount of Rs.55,130/- alongwith interest @ 12% per annum from 20.8.2014 till realization.
b) Opposite Party be directed to pay compensation of Rs.40,000/- to the complainant.
c) Opposite Party be directed to pay the adequate cost of litigation.
Hence, this complaint.
2. Upon notice, Opposite Party appeared and contested the complaint by filing written reply taking preliminary objections therein inter alia that the complainant has not come to this Forum with clean hands and has suppressed various material acts, as such, the complainant is not entitled to any relief from this Forum; that the complaint is liable to be dismissed as the complainant had taken treatment at Medanta, The Medicity at Gurgaon, Haryana and the cashless facility has been rejected from Gurgaon and further the said policy has also been issued from Gurgaon, hence the instant complaint is liable to be dismissed on the basis of territorial jurisdiction; that the complainant is estopped by his act and conduct from filing the present complaint; that no cause of action has ever arisen in favour of the complainant and against the answering Opposite Party; that the complaint of the complainant is legally not maintainable in the present form and as such, same deserves dismissal; that as per standard practice, the complainant Nitin Aggarwal, policy holder had submitted to the Opposite Party a duly filled and signed proposal/ application dated 25.3.2013 at Jalandhar Branch Office for the purchase of Easy Health Floater Plan from Apollo Munich Health Insurance Company, and the proposal was accepted on the standard rates based on the information provided by the Proposer and consequently the policy bearing No. 180200/11051/1000379918-01 dated 29.3.2013 was issued. Said policy was again renewed vide policy No. 180200/11051/1000379918-01 for the policy period 31.3.2014 to 30.3.2015. In this connection, the Opposite Party crave leave to refer to the first paragraph of the proposal form which is as follows:-
“We are under no obligation to accept any proposal form insurance. If we accept a proposal for insurance, it shall be subject to the policy terms and conditions……….”
The Opposite Party also craves leave to refer to the clause ‘General Exclusion’ as stated in PF which was duly signed and submitted by the complainant and the relevant paragraph reads as:-
“Conditions for which hospitalisation is not required. Experimental, investigation or unproven treatment devicies and pharmacological regimens.”
That the complainant provided the discharge summary on 20.8.2014 and few other documents. Upon scrutiny of the said documents, particularly discharge summary, it appeared that the insured/ complainant was admitted on 14.8.2014 to 20.8.2014 at Medanta, The Medicity Gurgaon, Haryana with complaints of difficulty in chewing, progressive weakness of muscles of face and upper limbs and early fatigability probable diagnosis of Myasthenia Gravis as per discharge summary. It is noteworthy to mention that the discharge summary also clearly stated that the complainant was admitted for further evaluation and management. On merits, facts narrated in the complaint are also denied and a prayer for dismissal of the complaint with cost was made.
3. In his bid to prove the case, complainant made in the witness box as his own witness and filed duly sworn affidavit Ex.C-1 in support of the allegations made in the complaint and also produced copies of repudiation letters Ex.C2 and Ex.C3, copy of claim file Ex.C4, copy of discharge summary Ex.C5, copies of medical certificate Ex.C6 to Ex.C8 and closed his evidence.
4. To rebut the evidence of the complainant, the Opposite Party tendered into evidence the copy of policy wording Ex.OP1 containing 19 pages, affidavit of Deepti Rustagi, Vice President-Legal Ex.OP1/A alongwith annexures A to H and closed the evidence.
5. We have heard ld.counsel for both the parties and have carefully gone through the evidence on record.
6. From the appreciation of the facts and circumstances of the case, it becomes evident that the complainant was hospitalised for the period from 14.8.2014 to 20.8.2014 at Medanta, The Medicity Gurgaon, Haryana on account of his illness i.e. Myasthenia Gravis. It is in evidence that the complainant incurred an amount of Rs.55,130/- on his medical expenses and treatment. It is also not disputed that the complainant was insured with Opposite Party for an amount of Rs.3 lacs vide insurance policy, copy whereof is Ex.OP1/A (Annexure-B) which covered risk period from 31.3.2014 to 1.4.2015. When the complainant submitted the claim to the Opposite Party, the Opposite Party repudiated the claim of the complainant on the ground that as per the clause ‘General Exclusion’, the conditions for which hospitalisation is not required. Experimental, investigation or unproven treatment devices and pharmacological regimens. Thus, it is quite evitable that as per the terms and conditions any treatment which had been admitted only for investigations and evaluation and the ailment can be treated on OPD basis where hospitalisation is not necessary, any claim arising is liable to be rejected as per the terms and conditions of the policy and we are under no obligation to accept any proposal for insurance. If we accept a proposal for insurance, it shall be subject to the policy terms and conditions…….” In the case in hand, it is the defence of the Opposite Party that no hospitalisation was required to be done and it was an OPD treatment and therefore, the claim has rightly been rejected.
7. But however, on the other hand, the complainant was admitted with disease myasthenia gravis, presented with difficulty in chewing and fatiquability and difficulty in gargling. He had few episodes of uneasiness and regular palpitation which were unlikely due to present disease and has been counselled for that as per. discharge summary Ex.C5. Medical history detailed in Discharge Summary-Neuro (document Ex.C6) narrates that Nitin Aggarwal, patient recently detected as myasthenia gravis, presented with difficulty in chewing and fatiquability and difficulty in gargling. He also had complained of mild dysponea. There was no history of diplopia/ loss of consciousness/ displegia/ headache. Patient was evaluated outside. MRI brain and CECT chest were done showed normal study. His RMST was borderline positive and Neostigmine test was positive. He was put on medications from outside with partial response. He was admitted here for further evaluation and management. From the Discharge Summary-Neuro Ex.C6, it becomes evident that the complainant was having difficulty in chewing and fatiquability and difficulty in gargling. He also complained of mild dysponea. In such a situation, the complainant could not have been treated by the hospital as OPD patient because his treatment required evaluation and management. Even medical certificate dated 16.8.2014 issued by the Treating Dr.Panilai Singh Ex.C7 clearly states that his management required emergency medical admission and observation for worsening of respiratory discomfort. He was evaluated by Senior Neurologist at the hospital and his medicines/ treatment has been stepped up. He needs to continue these Immunosuppcrants in near future post discharge/ stabilisation. The medical certificate dated 31.08.2014 issued by Dr.Sumit Singh of Medanta, The Medicity Gurgaon, Haryana also states that this neurological emergency and is life threatening, which is reproduced as under:-
“This is to certify that Mr.Nitin Aggarwal Age 28/M (UHID:MM005422217), is under my treatment in Medanta the Medicity from 14.08.14 he presented to us with complaints of breathlessness as well as weakness of facial and chewing muscles with severe palpitation. His symptoms were suggestive of disease and progression and impending myasthenic crisis. This is neurological emergency and is life threatening. His management required emergency medical admission and treatment for worsening for respiratory discomfort. His treatment has been stepped up & he needs to continue with us & be on immunosuppresants in near future post discharge/ stabilisation.”
There is nothing on record produced by the Opposite Party to prove that there was absolutely no need for the complainant to be treated as indoor patient in that hospital. No opinion of any doctor or medical expert has been adduced on record to counter the medical expert opinion as well as treatment record produced by the complainant. As such, in our considered opinion. The repudiation of claim vide letter Ex.C-2 is not sustainable at law. The opposite party is deficient in service. Hence the complainant is entitled to the medical insurance claim to the tune of Rs.55,130/- on account of reimbursement of medical treatment inclusive of expenditure on medicines. The complainant is also entitled to receive Rs. 5000/- as compensation for deficiency of service. The Opposite Party is directed to comply with the order within 30 days from the date of receipt of copy of this order, failing which, the awarded amount shall carry interest @ 9% per annum from the date of passing of the order until full and final recovery. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
Announced in Open Forum
Dated: 06.06.2016. (S.S.Panesar) President
(Anoop Sharma) (Kulwant Kaur Bajwa)
Member Member
hrg
