This case has arisen out of an application U/s 35 of the Consumer Protection Act, 2019.
The case of the complainant is that he purchased Health Insurance policy from Apollo Munich Health Insurance Company through O.P.No:2/Bank, subsequently O.P.No:2 shifted the policy to O.P.No:1/Bajaj Allianz GIC Ltd vide Policy No:OG-21-2414-6021-00000119 valid for the period from 09.10.2020 to 08.10.2021.
That suddenly complainant fell ill for kidney stone & upon advice of Dr. Dipak Dubey he got admitted in Manipal Hospital at Hal Airport Road, Bengaluru on 16.06.2021 where he was operated and discharged there from on 18.06.2021.
That thereafter, complainant on 16.07.2021 submitted claim form including original medical prescription etc, demanding sum of Rs.1,03,771/- for medical reimbursement but till date it has not been paid, thereby he has been suffering from monetary loss and subjected to mental pain and agony.
He thus prays for direction upon the O.Ps to pay sum of Rs.1,03,771/-, compensation of Rs.50,000/- for harassment, mental pain & agony and litigation cost of Rs.5,000/-.
O.P.No:2 submits W.V stating that O.P.No:2 is a corporate agent of O.P.No:1 & the complainant for security of himself and his family purchased the policy from Apollo Munich Health Insurance Company through O.P.No:2, subsequently shifted to O.P.No:1/Bajaj Allianz GIC Ltd. O.P.No:2 did not perform any whimsical activity towards complainant, the claim of the complainant is not settled by O.P.No:1 by some technical reason, perhaps it may be suppression of illness. O.P.No:2 is not responsible for payment of medical reimbursement & it seeks exoneration from the present case.
O.P.No:1 contested the case be filing separate W.V stating that complainant was issued a medical insurance policy under plan, namely, ‘Master Policy’ by O.P.No:1 bearing Policy No:OG-20-9999-9960-00000092 w.e.f 09.10.2020 to 08.10.2021 providing policy coverage to himself (herein after referred to as ‘insured’/policy holder) for a sum insured Rs.5,00,000/- subject to policy terms & conditions.
The O.P.No:1 received a claim form for cash facility from the complainant for his treatment. He has suppressed the fact in his claim form at the time of purchasing the medical insurance policy that he was suffering from the disease of “Nephrectomy, Chronic Kidney disease” since 2015 & his treatment was done in Mahipal Hospital, Hal Airport Road, Bengaluru.
An investigation was triggered by O.P.No:1 to check the veracity of the claim, further O.P.No:1 raised a query to medical documents and doctor’s prescription that he had been suffering for a long time for pre-existing disease (Bilateral Nephrocalcinosis Chronic kidney disease) before 09.10.2020 i.e prior the issuing mediclaim policy by O.P.No:1. Since the complainant purchased said health insurance policy from O.P.No:1 to have been suppressed his pre-existing disease to get illegal benefit from O.P.No:1 as such he has violated the terms & conditions of the policy & therefore, O.P.No:1 rejected/repudiated the request of the insured vide denial letter dated 18.06.2021. There was no deficiency on the part of O.P.No:1/insurer, thus it prays for dismissal of the case.
Point for consideration is:-
- Whether there was any deficiency in service on the part of the O.Ps which gives rise cause of action to file the complaint and the complainants are entitled to get the claim?
D e c i s i o n w i t h r e a s o n s
Admittedly, the complainant is an A/c holder of Canara Bank, Raiganj Branch (O.P.No:2), a banking organization and corporate agent of Apollo Munich Health Insurance Company.
In cross-examination the complainant/P.W.1 stated that from the end of O.P.No:2/Canara Bank he was told/informed that an OTP is to be generated for purchasing health insurance policy and accordingly, he received an OTP in his mobile phone & premium against purchase of said insurance policy was debited from his account by O.P.No:2/Bank. Though he stated that he was not interested to purchase health insurance policy but never he informed Canara Bank over phone or in written that he has no intention/interest to purchase said insurance policy or that he does not want to continue the policy & he was conscious that a health insurance policy was purchased from the end of Canara Bank in his name.
O.P.No:2/Bank submits questionnaire dated 22.03.2023 replied by complainant in affirmative that complainant maintained an account before the O.P/Bank and initially he is the customer of Apollo Munich Health Insurance Company and he sought claim against bank authority, but he replied in negative stating that the bank authority asked for OTP before purchasing said policy and both O.Ps are responsible for their deficiency in service.
O.P.No:2/Bank replied the questionnaire of complainant stating that bank cannot directly issue health insurance policy to the complainant. As per Insurance Company’s rules and being the customer of the same policy was issued. As per the mandate of the complainant O.P/bank deducted the premium amount and it is done through system and it is automatically processed.
Thus it appears that on the desire of complainant O.P.No:2/Bank applied for purchase of Apollo Munich Health Insurance Company’s policy through online (OTP based) and deducted the premium from complainant’s account & through online system policy was processed & issued in the name of the complainant. Initially complainant purchased Group Assurance Health Plan Insurance (Member ID EA01449427) from Apollo Munich Health Insurance Co. Ltd for a sum insured Rs.5,00,000/- for himself/insured, keeping his son Subhankar Roy as nominee, firstly covered from 09.10.2018 to 08.10.2019, then 09.10.219 to 08.10.2020.
According to O.P.No:2/Bank subsequent to merger of Syndicate Bank with Canara Bank w.e.f 01.04.2020 there was some problem in corporate level in respect of continuance of insurance policy from Apollo Munich Health Insurance Company & in that respect Bajaj Allianz GIC Ltd was substituted in the place of Apollo Munich & in this process general interest of customer was not hampered & the complainant, initial policy holder of Apollo Munich HIC Ltd became customer of O.P.No:1/Bajaj Allianz GIC Ltd vide Policy No:OG-21-2414-6021-00000119 valid for the period from 09 October, 2020 to 08 October, 2021, a Group Mediclaim of Canara Bank. The Bank replied that O.P.No:2 has no role to shift the policy from Apollo Munich to Bajaj Allianz (O.P.No:1). Both the companies are corporately tied up with O.P.No:2 and it is done in corporate level.
It is not disputed that the complainant fell ill & upon advice of Dr. Dipak Dubey he got admitted in Manipal Hospital at Hal Airport Road, Bengaluru on 16.06.2021 where he was operated and discharged there from on 18.06.2021.
Claim summary shows that the complainant requested for cashless hospitalization for Provisional Diagnosis:-B/L Ureteric calculi, vide Claim No:OC-22-1002-6021-00004301, date of intimation:16.06.2021, loss assessed amount: INR 94349, grounds of repudiation/closure:-
General Denial Clause-3.
.Liability of the insurer cannot be ascertained at this juncture.
Vide letter of denial of cashless facility dated 18.06.2021.
Complainant’s case is that on 16.07.2021 he submits claim form including original medical prescription etc, demanding sum of Rs.1,03,771/- for medical reimbursement. Xerox copy of text message dated 16.07.2021 of AD-BJAZGI, details:this is a system generated response to acknowledge receipt of your documents. The reference No is IN-2414-4823790. Health Administration Team, Bajaj Allianz GIC Ltd.
The case of the complainant is that several times he visited Branch offices of O.Ps but till today his claim amount has not been paid. Document produced by complainant shows that on 16.09.2021 the complainant lodged a complaint to the AD, CA & FBP, Uttar Dinajpur Regional Office, but neither disclosed it in petition of complaint nor the result of such complaint. The complainant thereafter, lodged a complaint letter to O.P.No:2 stating that-at the time of release from hospital his cashless facility has been declined by O.P.No:1 and after coming home again he filled up a claim form & send it to Insurance Company for reconsideration but no information is given. O.P.No:2 received the letter on 20.09.2021, with endorsement: will be forwarded to concerned authority.
No document is produced to show that the O.P.No:2 referred/forwarded the same to O.P.No:1. Fact remains the claim of the complainant has not yet been settled. According to O.P.No:1 for some technical reason perhaps it may be suppression of illness.
In cross-examination complainant stated that he is aware that in case of any treatment or hospitalization he may get the cost of treatment against the said policy. He admits that in the year 2015 he was treated at Manipal Hospital for kidney disease, again visited said hospital for treatment of same disease in the year 2021. He stated that never he told Canara Bank Authority to include/disclose his pre-existing disease in the Health Insurance Policy.
Again we reiterate that the Apollo Munich Health Insurance policy was purchased through online(OTP based) & system generated, first for the period 2018-19 & 2019-20, later migrated/shifted to Bajaj Allianz HIC Limited, for the period 2020-21 where there was no opportunity to medical examination prior to purchase of Health Insurance Policy, as mandated.
Ld. Advocate for the complainant argued that as per IRDA guidelines pre-existing disease is to be considered within 48 months from the date of purchase of the policy. O.P.No:1 submits policy schedule, the wording depicts:-
52. Pre-Existing Disease
Means any condition, ailment or injury or disease
- That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or
- For which medical advice or treatment was recommended by, or received from, a physician within 48 months prior to the effective date of the policy or its reinstatement.
C. Exclusion
We shall not be liable to make any payment for any claim directly or indirectly caused by, based on, arising out of or attributable to any of the following:-
- Waiting period
All illnesses, treatments and their associated complications shall be covered subject to the waiting periods specified below:-
- Pre-existing Diseases waiting period (Excl01)
- Expenses related to the treatment of a pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of 36 months of continuous coverage after the date of inception of the first policy with us.
Admittedly, the complainant had been suffering for a long time for pre-existing disease (Bilateral Nephreocalcinosis Chronic Kidney disease) before 09.10.2020 i.e prior the issuing mediclaim policy by O.P.No:1 & since 2015 under treatment of Manipal Hospital, Bengaluru, the complainant found purchased said Health Insurance Policy to have been suppressed his pre-existing disease & violated the terms & conditions of the policy.
As there was no occasion of pre-policy medical examination & waiting period has not been covered with O.P.No:1, we find no deficiency in service on the part of O.P.No:1 to reject/repudiate complainant’s claim. Also we find no deficiency on the part of the O.P.No:2/Bank who acted as corporate agent only. Consequently, we find that the complainant is not entitled to get claim as prayed for.
In the result the case fails.
Hence, it is
O R D E R E D
that the C.C-48/2022 be and the same is dismissed on contest against the O.Ps but without any cost.
Let a copy of this order be given to the parties free of cost.
