Tripura

StateCommission

A/35/2021

Smt. Namita Paul - Complainant(s)

Versus

Appolo Munich Health Insurance - Opp.Party(s)

Mr. K. Pandey, Mr. R. Datta

10 May 2022

ORDER

State Consumer Disputes Redressal Commission TRIPURA: Agartala

 

 

Case No. A.35.2021

 

 

 

 

Smt. Namita Paul,

W/o Sri Swapan Kumar Paul,

Resident of Banamalipur,

P.O. Agartala, P.S. East Agartala,

District-West Tripura.  

… … … … Appellant

 

VERSUS

 

 

 

1. Apollo Munich Health Insurance,

Represented by its authorized signatory/representative,

Ground Floor Srinilaya,

CyberSpazio Road No.2,

Banzara Hills, Hyderabad-500034,

Telengana.

 

2. Authorized Signatory/Representative,

Apollo Munich Health Insurance,

Ground Floor Srinilaya,

CyberSpazio Road No.2,

Banzara Hills, Hyderabad-500034,

Telengana.

 

3. Authorized Signatory/Representative,

Apollo Munich Health Insurance,

Agartala Branch, Canara Bank,

B.K. Road, Banamalipur,

Agartala, P.O. Agartala, P.S. East Agartala,

District-West Tripura, Pin-799 001. 

 

4. Mr. Sayantan Das,

In-charge, Apollo Munich Health Insurance,

Agartala Branch, Canara Bank,

B.K. Road, Banamalipur, Agartala,

P.O. Agartala, P.S. East Agartala,

District-West Tripura, Pin-799 001. 

 

5. Canara Bank, 

Head Office, 112, J.C. Road,

Bangalore-560 002, Represented by its Chairman.

 

6. The Chief Manager,

Canara Bank, Agartala Branch,

B.K. Road, Banamalipur, Agartala,

West Tripura, Pin-799 001.

 

7. Mr. Arunabhoy,

Canara Bank, Agartala Branch,

B.K. Road, Banamalipur, Agartala,

West Tripura, Pin-799 001.

 

8. Marketing Officer,

Canara Bank,

Agartala Branch, B.K. Road,

Banamalipur, Agartala,

West Tripura, Pin-799 001.

 

9. HDFC ERGO Health Insurance Company Limited,

1^st Floor, HDFC House, Backbay Reclamation,

H.T. Perekh Marg Churchgate, Mumbai-240 020,

Represented by its authorized person,

 

10. HDFC ERGO Health Insurance Company Limited,

Agartala Branch, B.K. Road,

Banamalipur, Agartala,

P.O. Agartala, P.S. East Agartala, West Tripura,

Represented by its authorized representative

 

… … … … Respondent-OPs.

 

 

B E F O R E

HON’BLE MR. JUSTICE ARINDAM LODH

PRESIDENT, State Commission

 

Dr. Chhanda Bhattacharyya

Member, State Commission

Mr. Kamalendu Bikash Das

Member, State Commission

 

 

 

 

For The Appellant                       :         Mr. Raju Datta, Advocate .

For the Respondent                     :         Mr. S. Chowdhury, Advocate    

Date of Hearing & delivery

of Judgment and order                  :         10.05.2022

 

 

 

J U D G M E N T (ORAL)

       This is an appeal preferred by the policy holder-consumer of Apollo Munich Health Insurance against the judgment dated 22.10.2021, passed by the learned District Consumer Redressal Commission, West Tripura, Agartala in connection with Case No.CC 87 of 2018.

2.             Shortly stated, the appellant-consumer had purchased one health insurance policy, namely Easy Health Group Insurance vide Policy No.120100/12001/2017/A007068/PE00518069 from Apollo Munich Health Insurance through OP No.6. Sum assured was Rs.10,00,000/- and optional critical sum insured was Rs.50,000/- w.e.f. 28.03.2017 to 27.03.2018. The complainant-appellant had paid Rs.8,697.61 towards the premium for Canara Bank Group Insurance No.A007068 for the period from 28.03.2017 to 27.03.2018.

3.             On 07.11.2017, suddenly the appellant-complainant felt chest pain and immediately she met Dr. Chayan Bhattacharjee in his chamber at Agartala, West Tripura, who prescribed her some medicines and advised her for admission in any specialty hospital. Then, the appellant-complainant admitted in ICU of ILS Hospital, Agartala. But, due to insufficient medical facilities in the ILS Hospital, Agartala, the complainant left the said hospital on 08.11.2017 and admitted in AMRI Hospital, Mukundapur, Kolkata wherein Dr. Uttam Kumar Saha, Chief Interventional Cardiologist and his team started her treatment and conducted Coronary Angiogram and Angioplasty on her. She was treated in the said hospital upto 11.11.2017 and for that purpose she had to incur expenditure for an amount of Rs.1,71,840/-.

4.             It is the claim of the complainant that during her treatment and at the time of discharge, the OP No.1 rejected the cashless claim of the complainant. However, the complainant informed the matter to OP No.6 and thereafter, on her arrival at Agartala, the complainant met with OP No.6 for settling her claim and submitted the claim petition along with all supporting documents on 07.12.2017. But, unfortunately, after a lapse of considerable period i.e. on 09.02.2018 she received a communication from OP No.6 wherein it was stated inter alia that ‘all the documents need to be submitted in original copies’. Accordingly, on 08.03.2018, she submitted all the original documents.

5.             Thereafter, on 22.03.2018, OP No.1 had issued a letter asking her to submit some additional documents to settle the issue of payment of the medical claim to the complainant. In reply to that query letter, the complainant issued a letter to the OPs requesting them to release the claimed amount of Rs.1,71,804/-. Thereafter, on 11.04.2018, the OP No.5 had issued a letter to the husband of the complainant to furnish the following documents:

“a. Treating doctor’s Certificate Regarding Duration of heart disease with first consultation letter,

b. Treating Doctor’s Certificate regarding duration of Seizure Disorder with first consultation letter.”

6.             In reply, the complainant had issued a letter to the OPs stating that Dr. U.K. Saha at the time of admission of the complainant at AMRI Hospital, Kolkata on 08.11.2017 speculated that the appellant suffered with seizure disorder. Thereafter also, the complainant had issued several reminders including e-mails to the OPs requesting them for releasing the said amount, but, the OPs did not release the said amount in favour of the complainant. As a result, the complainant had to suffer huge mental depression and agony and she also failed to concentrate in her business for which she had to incur huge loss in her business.

7.             Finding no other alternative, the complainant filed a complaint petition before the learned District Commission, West Tripura, Agartala claiming reimbursement of medical expenditure for an amount of Rs.1,71,804/- along with interest at the rate of 12% and also claimed for Rs.3,00,000/- for mental agony and sufferings as well as Rs.5,00,000/- for the loss of her business. 

8.             The Insurance company, i.e. the Apollo Munich Health Insurance contested the complaint petition by filing written objection. The OP No.6 also contested the complaint petition by filing separate written objection. At the stage of argument, the complaint petition was allowed to be amended by the learned District Commission on the prayer of the appellant and OP Nos.9 and 10, namely HDFC ERGO Health Insurance Co. Ltd. and HDFC ERGO Health Insurance Co. Ltd., Agartala Branch respectively were impleaded as opposite parties and notices were issued upon them, but, OP Nos.9 and 10 did not turn up despite receiving notices and, accordingly, the learned District Commission decided to proceed ex parte against OP Nos.9 and 10.

9.             In the written objection filed by OP No.6, it is stated that the complaint filed by the complainant is not maintainable in law as well as factual aspects. The OP No.6, being an agent of Apollo Munich Health Insurance sold the policy and collected the premium, and hence, the OP No.6 is not a necessary party to the lis and it has no obligation to settle the claim and the complaint is not maintainable against respondent-OP No.6.

10.           On the other hand, the OP Nos.1 to 4, i.e. Apollo Munich Health Insurance by filing common written objection have stated that they are the registered company and the complaint filed by the complainant against them is vague, false, vexatious and frivolous without merit and the same ought to be dismissed. It is further stated that the learned District Commission has no jurisdiction to entertain the complaint petition and the same is liable to be dismissed as not maintainable.

11.           After exchange of pleadings, evidences of the contesting parties were recorded. The complainant submitted her examination-in-chief as PW1 and examination-in-chief of her son, namely Suvajit Paul as PW2 and adduced some documents(12 nos.) which were marked as Exbt.1 series.

12.           On the other hand, one Supriyo Chakraborty, agent of Apollo Munich Health Insurance also submitted examination-in-chief on affidavit on behalf of the OP No.6. 

13.           After closure of recording evidence, the learned District Commission had formulated two points for determination, which are as under:

“(i)    Whether there is deficiency of service on the part of the OPs?

(ii)    Whether the complainant is entitled to get compensation/relief as prayed for?”

14.           Having gone through the records, and on consideration of the submissions of the learned counsels appearing for the parties to the lis, the learned District Commission held that the complainant had failed to substantiate the claim and accordingly dismissed the complaint.

15.           Feeling aggrieved, and dissatisfied with the said judgment and findings thereof, the complainant has preferred the instant appeal before this Commission.

16.           Mr. Datta, learned counsel appearing on behalf of the appellant has submitted that the respondents-OPs had arbitrarily repudiated the claim of the complainant-appellant. Learned counsel has further submitted that the findings of the learned District Commission are perverse and contrary to law. Mr. Datta, learned counsel for the appellant has further submitted that at the time of purchase of the said insurance policy, the complainant was asymptomatic of the related disease. The treating Doctor of AMRI Hospital, i.e. Dr. U.K. Saha had issued a certificate where he categorically stated that after being diagnosed, the complainant underwent Angiogram and Angioplasty and, though, she was admitted on the speculation that she was suffering from seizure disorder, but, on being diagnosed, it was found that she was not suffering from active seizure disorder, but for other heart diseases as stated here-in-above. After receipt of the said certificate, the complainant had communicated the same to the respondent-OPs with a further request to make payment of the amount which she incurred out of her treatment in AMRI Hospital, Kolkata.  

17.           We have gone through all the documents as being brought on record by the complainant.  

18.           Resisting the submissions of the learned counsel appearing on behalf of the appellant, Mr. Chowdhury, learned counsel appearing for the Apollo Munich Health Insurance has submitted that at the time of purchase of the policy, the complainant had made false declaration in the prescribed form. According to learned counsel for the respondents, the complainant failed to declare that she was suffering from her illness prior to filling up the prescribed form, and she suppressed the same. Learned counsel for the respondents has further contended that during the course of correspondences with the complainant as well as the authorities of AMRI Hospital, Kolkata, it was revealed that the complainant had been suffering from heart disease for the last six years.   

19.           We have considered the rival submissions advanced by the learned counsels appearing for the parties.

20.           Having gone through the evidences on record and the documents introduced in course of recording of evidence, it comes to light that Dr. Uttam Kumar Saha, the Chief Interventional Cardiologist of AMRI Hospital, Kolkata had issued a certificate inter alia stating that the complainant was admitted in the hospital under his care and the patient underwent Coronary Angiogram and Angioplasty on 08.11.2017. The doctor has clearly stated that “She is not having any active seizure disorder at present. Present admission has no relevance with seizure disorder”.  

21.           Taking into consideration the submission of learned counsels appearing for the respondents-Insurance company in respect of the fact that the complainant was suffering from heart disease for last six years, in our opinion, though, for argument sake, it is believed that the complainant was suffering from heart illness for the last six years, but there is no such evidence, and doctor also did not certify anything that during those six years, the complainant had any complain of heart disease.

22.           It is categorically stated by the complainant in her evidence as well as in the complaint that for the first time she experienced problem in her heart in the month of November, 2017 and immediately she visited Dr. Chayan Bhattacharjee in his chamber for treatment and on his advice the complainant first got admitted in the ILS Hospital, Agartala for specialty treatment and due to insufficient medical facilities therein, the complainant had preferred to rush to Kolkata and admitted at AMRI Hospital under the care of Dr. Uttam Kumar Saha where she was treated.

23.           According to us, a person can suffer from any disease for many years, but, in absence of any symptom it cannot be speculated that such person is suffering from a disease for last six/seven years and for that reason his/her claim under the policy should not be repudiated. Besides, we do not find any contrary certificate as to the certificate issued by Dr. U.K. Saha on 11.11.2017. Furthermore, it is the normal practice of the Medical Insurance companies that they issue Medical Insurance Certificate on being wholly satisfied with the declaration given by the purchaser.

24.           The findings of the learned District Commission that the complainant did not produce necessary medical report/documents are found to be perverse. All the relevant documents have been submitted by the complainant during her evidence which were also exhibited. There is no contrary evidence in respect of the disease of the complainant. Mere filing of a document without its proof in accordance with law will not tantamount that the document has been proved. After perusal of the records of the learned District Commission, it is reiterated that the respondents did not file any such document as contended by the learned counsel for the appellant, which is contrary to the certificate dated 11.11.2017 issued by Dr. Uttam Kumar Saha.    

25.           Situated thus, and on overall circumstances of the evidences on record, we find merit in this appeal compelling us to interfere with the judgment of the learned District Commission.

26.           Accordingly, the judgment dated 22.10.2021 passed by the learned District Commission in case No.CC 87 of 2018 stands set aside and quashed. The claim of the complainant to the extent that she is entitled to get Rs.1,71,804/- which she spent for her treatment is allowed. We further quantify compensation at Rs.50,000/- for deficiency in service on the part of the respondent-OPs and Rs.25,000/- for mental agony suffered by the complainant. In total, the appellant-complainant will be entitled to Rs.2,46,804/-[Rs.1,71,804+Rs.50,000/-+Rs.25,000/-] and the liability for such payment is fastened with respondent No.6, the Chief Manager, Canara Bank, Agartala Branch. Further, the said amount of Rs.2,46,804/-(Rupees two lakh forty six thousand eight hundred four) shall carry interest at the rate of 7% per annum, if it is paid within a period of six weeks from today, otherwise, the entire amount shall carry interest at the rate of 12% per annum till the date of realization. 

27.           The appeal accordingly stands allowed and thus disposed of as indicated above.