ORDER

23.02.2024

MS. NIPUR CHANDNA, MEMBER

1. In brief facts of the present case are that complainant had taken a medical insurance policy namely “Optima Restore Insurance Policy” from Apollo Munich Health Insurance Co. Ltd. on 01.03.2013. The policy no. is 110106/11121/6000083827 and period 27.02.2013 to 26.02.2014 and basic sum assured was Rs.5,00,000/- only. It is stated that complainant went for a preventive health checkup on 07.05.2013 in a routine manner at Max Hospital, Saket, Delhi and under the comprehensive health checkup scheme interalia a treadmill test was also done. It is further stated that during the test the petitioner was diagnosed positive in the T.M.T test, hypersensitive and diabetic. It is stated that Max Hospital advised to go for an angiography.

2. It is stated that on 15.05.2013 complainant went to Indraprastha Apollo Hospital with complaint of chest heaviness. The experts at Apollo Hospital did coronary angiography which revealed coronary artery disease with multiple vessel blockage and was advised to get admitted on the same day for investigation in order to carry out coronary artery bypass grafting surgery (CABG). It is stated that after all the necessary investigations CABG was performed on 17.05.2013, thereafter, complainant remained in ICU for needful and ultimately discharged on 25.05.2013. It is further stated that complainant has incurred medical expenditure in the aforesaid by pass surgery which the respondent are legally bound to indemnify. The total expenditure as claimed in the present complaint is 4,94,478 + interest @ 18%, it also includes mental agony, harassment and litigation expenses as well.

3. It is further stated that complainant submitted documents which are relevant on 14.06.2013 at the Pritam Pura office of Apollo Munich which includes original discharge summary, all original prescriptions for treatment pre and post, duly filled and signed claim form, all test and lab reports, all x rays and other scanned reports, copy of the original policy, ID proof, cancelled cheque of his saving account, pre surgery reports wherein the complainant was diagnosed with heart problem from Max hospital, treating doctors statement for first diagnosis of the problem, treating doctors certificate for exact duration of DM/HTN/IHD on his letter head, final bill and all medicine bills and prescriptions relating to treatment. The complainant had also given a covering letter at the time of submitting the aforesaid documents at Pitam Pura office.

4. It is further stated that in first week of July, complainant had received a letter from The Family Health Plan (TPA) signed on 22nd June,2013 thereby demanding more documents i.e copies of indoor case papers of hospitalization including admission note and daily progress notes, breakup of cath consumable of Rs.8559/-, health checkup record, previous health record and TMT done before hospitalization, original consolidated final bill and residence proof showing policy main member name. It is further stated that complainant had submitted all the relevant documents on 14.06.2013, however, to eliminate all confusion on 06.07.2013 the additional documents also submitted.
5. It is stated that on 22nd July complainant received call from Ms. Anchal ID.631644 requesting reports of Max hospital including TMT done on 07.05.2013 during preventive health checkup, however, to satisfy insurance company he would again sent all the reports of Max including TMT once again and thereafter sent the documents on 24 july to Ms. Anchal FHPL, Gurgaon by DTDC courier.

6. It is stated that respondent repudiated the claim of complainant on 29.07.2013 on grounds which are not applicable in the  instant case. It is further stated that complainant has been deprived of his rightful claim in an arbitrary, malicious and illegal manner and proper mind has not been applied resulting in deficiency of service.

7. It is stated that the documents were first submitted on 14.06.2013, thereafter, additional documents were submitted on 06.07.2013, again additional documents submitted by courier on 24.07.2013, thereafter, complainant personally submitted all requested documents on 02.08.2013, therefore, there is deficiency of service on the part of insurance company. It is further stated that the disease relating to multiple artery blockage was new and was found for the first time on 15.05.2013 when angiography was done in Apollo Hospital. It is stated that the blockages were substantial between 90-95% and the expert Heart Specialist advised that it was an emergency situation and complainant needed to undergo CABG without losing time.

8. It is stated that complainant has a bonafide case which is evident from each and every document but insurance company fraudulently denying a truthful claim. Being aggrieved by the conduct of the OP and the repudiation of genuine claim, complainant approached this Commisson for redressal of his grievance.

9. Notice of the complaint was sent to OPs. OP-1 filed detailed WS thereby denying the deficiency in service on its part.

10. It is stated that to process the claim of the complainant certain documents were required and those were asked from the complainant but complainant in a complete lackadaisical manner did not yield to the request and reminders as a result the claim of the complainant was closed for deficiency of documents.

11. It is stated that post scrutiny of the submitted documents it was revealed that the complainant was a case of strongly positive TMT and angina and also diagnosed for diabetes II weeks back and he was admitted for angiogram. It is further stated that complainant was asked for some additional information relating to disease and history through letter dated 15.05.2013. The Max hospital stated that the complainant was suffering from Exertional Angina for the past one year as per letter dated 16.05.2013 and based on the history, the cashless facility was not granted. It is further stated that later on complainant lodged a claim on 17.06.2013 for reimbursement. The post scrutiny of the claim documents it was noted from the discharge summary that the complainant was admitted at the Indraprastha Apollo Hospital with complaints of chest pain on and off since few days back.

12. It is stated that the complainant was previously treated in Max hospital with history of chest heaviness. It is further stated that the past medical documents relating to Exertional Angina became necessary to rule out any possibility of previous existing  disease i.e prior to start policy with the answering OP.

13. It is stated that the consultation letter dated 13.05.2015 of Max hospital categorically points out that the complainant was suffering from Exertional Angina for the past one year. Thus, as per the policy terms and condition, the previous documents are  necessary to evaluate the admissibility of the claim/character of risk associated with the time of inception of policy so to estimate the degree of risk to ascertain whether the claim is admissible or not which the complainant is not providing for the best known reason to him inspite of repeated reminders. It is further stated that on 02 august answering OP again received a representation from complainant to reopen the claim and investigation report dated 04.8.2013 was also reviewed. It is stated that after reviewing all the medical documents and the investigation reports, it is crystal clear that the details of previous treatment is very important to adjudicate this case. As the policy is fresh with OP, so the claim was closed due to non submission of the required documents and letter dated 17.08.2013 communicated to complainant. OP1 referred to judgment of Devender Kumar Verma Vs. The Oriental Insurance Co. Ltd. RP No.2416 of 2013 and United India Insurance Co. Ltd. Vs. Harchand Rai Chandan Lal Civil Appeal No.6277 of 2004 (Supreme Court).

14. Complainant filed rejoinder to the WS of OP1 and denied all the allegations made therein and reiterated contents of the complaint.

15. OP2 Family Health Plan TPA Ltd. as per record served but failed to appear, therefore, proceeded ex parte.

16. Complainant filed evidence by way of his affidavit and reiterated contents of the complaint. Complainant relied on copy of optima restore policy schedule dated 27.02.2013 Ex.CW1/1, copy of report of max hospital dated 07.05.2013 Ex.CW1/2, copy of invoice cum bill dated 07.05.2013 of max hospital Ex.CW1/3, copy of admission and check up cum medical record of Apollo Indraprastha Hospital dated 15.05.2013 to 25.05.2013 Ex.CW1/4/A, copy of discharge summary Ex.CW1/4/B, copy of angiography report Ex.CW1//C copy of inpatient bill of Apollo hospital dated 25.05.2013 Ex.CW1/5, copy of letter dated 12.06.2013 of Apollo Munich Health Insurance co. Ex.CW1/6, copy of letter of TPA dated 22.06.2013 Ex.CW1/7, copy of DTDC courier dated 24.07.2013 of Apollo Munich with covering letter Ex.CW1/8, copy of mail addressed to FHPL dated 01.08.2013 Ex.CW1/9, copy of document dated 02.08.2013 for reopening of claim and email conversation with FHPL Ex.CW1/10, copy of receipt dated 02.08.2013 issued by FHPL Ex.CW1/11, copy of letter dated 09.08.2013 Ex.CW1/12 and copy of letter of Apollo munich-FHPL dated 17.08.2013 Ex.CW1/13.

17. OP1 filed evidence by way of affidavit of Ms.Deepti Rastogi Vice President Legal. In the affidavit contents of WS reiterated. OP relied on copy of authority letter dated 02.03.2015 Ex.OP1/A, copy of proposal form, policy schedule and policy terms and conditions Ex.OP-B, copy of request of cashless payment from Indraprastha Apollo Hospital Gurgaon dated 15.05.2013 Ex.OP-C, copy of queries raised to treating doctor Ex.OP-D, reply dated 16.05.2015, consultation letter dated 13.05.2015 and the rejection letter dated 16.05.2015 Ex.OP-E, Ex.OP-F and Ex.OP-G respectively, copy of letter dated 22.06.2013 Ex.OP-H, copy of letter dated 29.07.2013 Ex.OP-I and copy of investigator report Ex.OP-J.

18. Written arguments filed on behalf of complainant as well as OP1.

19. We have heard Sh. Arup Banerjee ld. counsel for complainant. There is no assistance on behalf of OP. Neither any representative or counsel for OP appeared for arguments despite ample opportunities given. We have gone through the voluminous record.

20. The facts admitted by OPs such as the policy in question, treatment undergone by the complainant, medical expenses incurred, claim submitted by the complainant. The sole question needs to be decided in the present complaint case is that whether the repudiation of the claim on account of non submission of document by OP Ins. Co. is justified or not. The OP Ins. Co., as per the repudiation letter dated 29.07.2013 closed the claim of the complainant by stating the reason that in spite of reminder dated 16.07.2013 the complainant has not provided the requisite documents as requested.

21. We have carefully gone through the letter dated 11.07.2013  and found that in this letter the complainant has already submitted the documents mentioned at point-1,2,5 & 6 and the OP has also admitted the same. As per the 2^nd reminder dated 16.07.2013 the OP Ins. Co. had only asked for the following documents:-

1. kindly provide health checkup record dated 07.05.2013 in Max Hospital
2. kindly provide the previous treatment record and TMT was done before hospitalization.
3. the OP Ins. Co. has already been provided with the copy of the  health check up record dated 07.05.2013 of Max Hospital and in respect to previous treatment the complainant submits that he had never undergone any treatment in respect to the ailment in question.

22. On the one hand the OP Ins. Co. denied the entire claim of the complainant on non submission of the documents, on the other hand the OP Ins. Co. itself in its written statement admitted that from the post scrutiny of the claim documents it was noted from the discharge summary that the complainant was admitted at the Indraprastha Apollo Hospital with complaints of chest pain on and off since few days back.

23. The OP Ins. Co. in its reply at para 14 itself admitted that for assessment of the claim in question and for having a fair review on the claim of the complainant the OP had also investigated the claim by 3^rd party who had categorically provided that “according to the insured he went up a routine checkup at Max Hospital on 07.05.2013 and was diagnosed to have been suffering from Hypertension and DM”. it is further stated in the written statement that the health checkup report of the complainant suggested that complainant is a case of hypertension and diabetic and on treatment which suffice that HTN and DM was diagnosed elsewhere and not on 07.05.2013.

24. The bare perusal of the aforesaid submission of OP Ins. Co. clarify that even after conducting the investigation when the OP Ins. Co. does not get the desire result/finding from the investigating agency further on the basis of suspicion/doubts and in order to withhold the genuine claim asked the complainant to run from pillar to post for getting the treatment record of those ailments for which he had never been diagnosed and was treated.

25. The complainant has placed on record the copy of discharge summary issued by treating doctor in which at the point of final diagnosis following remarks were made by the doctor:-

“Atherosclerotic coronary artery disease, triple vessel disease, critical vessel block, recent unstable angina, Good LV, recent hypertension and diabetic, Mild MR”

26. The bare perusal of the aforesaid discharge summary clearly establish the averments of the complainant as well as the genuiness  of the claim in question. The OP Ins. Co. despite engaging the 3^rd party agency for investigating the claim in question failed to place on record any documentary evidence to support the closure of the claim in question. Under the pretext of repeatedly demanding the documents those are already submitted the OP Ins. Co. had arbitrarily close the claim of the complainant. This act of OP-1 amounts to deficiency in service on the part of OP-1. We therefore hold OP-1 guilty of deficiency in service and direct it as under:-

i) pay to the complainant a sum of Rs. 3,44,478/- along with interest @ 6% per annum from the date of filing of complaint i.e. 23.03.2015 till realization.

ii) pay to the complainant sum of Rs. 20,000/- on account of pain and mental agony suffered by him.

iii) pay to the complainant sum of Rs. 10,000/- on account of litigation cost.

27. The OP-1 is directed to comply the order within 30 days of the receipt of the order failing which OP-1 will be liable to pay the aforesaid amount along with interest @ 9% P.A from the date of receipt of order till realization. File be consigned to record room.
28. Copy of the order be given to the parties free of cost as per order dated 04.04.2022 of Hon’ble State Commission after receiving an application from the parties in the registry. The orders be uploaded on www.confonet.nic.in.

Announced in open Commission on  23.02.2024.

SANJAY KUMAR                 NIPUR CHANDNA                       RAJESH

       PRESIDENT                             MEMBER                                MEMBER