Chandigarh

StateCommission

A/27/2019

Apollo Munich Health Insurance Company Ltd. - Complainant(s)

Versus

Hemant Thakur - Opp.Party(s)

M L Singhi, Nitesh Singhi, Priya Singhi, Adv.

11 Feb 2019

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

 

 

Appeal No.	:	27 of 2019
Date of Institution	:	07.02.2019
Date of Decision	:	11.02.2019

 

1]     Apollo Munich Health Insurance Co. Ltd., Corporate Office,    2^nd & 3^rd Floor, iLabs Centre, Plot No.404-405, Udyog Vihar,         Phase-III, Gurgaon – 122016.

2]     Apollo Munich Health Insurance Co., 1^st Floor, SCF No.19,    Sector 15, Gurgaon – 122001.

3]     Apollo Munich Health Insurance Co., Regd. Office Apollo        Hospital Complex, Jubilee Hills, Hyderabad – 500033.

 4]    Apollo Munich Health Insurance Co., Branch Office        Manimajra, 1^st Floor SCO 857, Shivalik Enclave, Manimajra,         U.T., Chandigarh.

 …….Appellants/Opposite Parties No.1 to 4.

 

Versus

 

Hemant Thakur S/o L. Sh. Balbir Singh, aged about 46 years, R/o H.No.5921, Modern Housing Complex, Manimajra, U.T., Chandigarh.

 

...Respondent/Complainant.

 

Appeal under Section 15 of the Consumer Protection   Act, 1986 against order dated 19.11.2018 passed by District   Consumer Disputes Redressal Forum-II, U.T. Chandigarh in Consumer Complaint No.299 of 2018.

 

BEFORE: JUSTICE JASBIR SINGH (RETD.), PRESIDENT.

                MRS. PADMA PANDEY, MEMBER.

                MR.  RAJESH  K.  ARYA, MEMBER

 

Argued by:

 

Sh. Nitesh  Singhi, Advocate for the appellants.

 

PER  RAJESH  K.  ARYA, MEMBER

                   The appellants/opposite parties No.1 to 4 have filed this appeal against order dated 19.11.2018 passed by District Consumer Disputes Redressal Forum-II, U.T., Chandigarh (in short ‘the Forum’ only), vide which, complaint bearing No.299 of 2018 filed by the respondent/complainant was partly allowed in the following manner:-

“14]      In view of the above findings, the complaint is allowed with directions to the Opposite Parties No.1 to 4/Apollo Munich Health Insurance Company to reimburse an amount of Rs.44,820/- to the complainant and also to pay compensation of Rs.15,000/- for causing him mental & physical harassment, along with litigation cost of Rs.7000/-.

        The Opposite Parties No.1 to 4/Apollo Munich Health Insurance Company is also imposed with penalty cost of Rs.2.00 lacs on account of their misdeed, as discussed above, which shall be deposited with Department of Radiotherapy & Oncology, PGIMER (Post Graduate Institute of Medical Education & Research), Chandigarh, through its Head of Department, for its usage for the treatment of needy/poor patients. 

15]      This order shall be complied with by the Opposite Parties No.1 to 4 in toto within a period of 30 days from the date of receipt of copy of this order, failing which it shall also be liable to pay additional compensatory cost of Rs.10,000/- to the complainant.

         In case the OPs No.1 to 4 failed to deposit the penalty amount with Department of Radiotherapy & Oncology, PGIMER (Post Graduate Institute of Medical Education & Research), Chandigarh, the Head of that Department shall be at liberty to take due recourse of law, which it deem proper, in order to recover the awarded penal amount.”

                However, the complaint against Opposite Party no.5 ( Paras Bliss Hospital) was dismissed by the Forum.

2.              Before the Forum, it was case of the complainant that he had subscribed and was issued a cashless ‘Easy Health Floater Standard’ Health Insurance Policy by Opposite Parties No.1 to 4 for the period from 28.2.2017 to 27.2.2018 after receipt of premium of Rs.12,171/- (Annexure C-1).  It was further stated that the complainant fell ill and remained hospitalized from 13.2.2018 to 16.2.2.2018 at Opposite Party No.5 - Paras Hospital, Panchkula and was diagnosed & treated for Typhoid. It was further stated that during investigations, another problem known in medical terminology as B/L Nasal Polyps was diagnosed, for which, no treatment was given. It was further stated that the bill of Rs.44,820/- was paid by the complainant to the hospital at the time of discharge as Opposite Parties No.1 to 4 wrongly denied the cashless facility (Annexure C-2).  It was further stated that thereafter, the complainant submitted a claim along with all requisite documents to Opposite Parties No.1 to 4 on 19.2.2018 for reimbursement of Rs.44,820/- but the same too was declined vide letter dated 22.2.2018 stating that the disease known as “Bilateral Nasal Polyps” was not covered under the policy (Annexure C-8) and falls under the exclusion clause.  It was further stated that the complainant was not treated for the said “Bilateral Nasal Polyps” but was treated for fever (Typhoid).  Alleging said repudiation as illegal and deficiency in service, complaint was filed before the Forum.

3.             Opposite parties No.1 to 4, in their reply, while admitting the factual matrix of the case, stated that during investigation, the treating doctor submitted a certificate that the complainant was suffering from Pansinusitis, Nasal Polyps and deviated nasal septum.  It was stated that as per Discharge Summary, the complainant was diagnosed of Pansinusitis with Nasal Polyp.  It was further stated that the claim of the complainant was analyzed by the in-house doctor of opposite parties No.1 to 4 and it was found that the claim was not payable because as per available medical documents of the complainant, for which treatment was sought, comes under the 2 years exclusion list of the policy terms & conditions i.e. the treatment of the complainant was excluded from the policy if admitted in 2 years of policy inception date.  It was further stated that the illness of the complainant had specific 2 years of waiting period as per policy and policy start date was 28.2.2017 and the treatment was taken from 13.2.2018 to 16.2.2018.  It was further stated that the claim was rightly repudiated (Annexure R-7). It was further stated that neither there was any deficiency, in rendering service, on the part of opposite parties No.1 to 4 nor they indulged into any unfair trade practice. The remaining averments were denied being wrong.

4.             Opposite Party No.5 in its short reply stated that the complainant approached the Hospital on 13.2.2018 with compliant of high fever which was diagnosed as Typhoid by the expert doctors attending the complainant.  It was further stated that during further investigations, the Hospital detected another problem known as ‘Bilateral Nasal Polyps” but the complainant did not go ahead with the treatment as the insurance company refused to provide cashless facility.  It was further stated that the complainant was discharged on 16.2.2018 after treatment of Typhoid and for ‘Bilateral Nasal Polyps’, he was advised to follow-up with ENT OPD. It was further stated that neither there was any deficiency, in rendering service, on the part of opposite party No.5 nor it indulged into any unfair trade practice. The remaining averments were denied being wrong.

5.            The parties led evidence. The Forum, on analysis of pleadings of the parties, documents on record, and the arguments addressed, partly allowed the complaint as referred to above.

6.             The appellants/opposite parties No.1 to 4 have assailed the impugned order passed by the Forum on the ground that the Forum wrongly relied upon the written statement of Opposite Party No.5, who had wrongly alleged that the complainant had approached the hospital on 13.02.2018 with the complaint of high fever, which was diagnosed as Typhoid by the hospital. It was further submitted that the Forum also failed to consider the Discharge Summary & Medical Test Reports issued by the said treating hospital, which was contradictory to the stand taken by the complainant as well as Opposite Party No.5, which clearly showed that the complainant was diagnosed with B/L Nasal Polyps and Pansinusitis and was tested negative for Typhoid, Malaria, dengue & urinary infections, henceforth making it evidently clear that respondent’s diagnosis of Pansinusitis was the only and root cause of his fever and the Forum wrongly relied upon the allegation of the complainant, which are without any evidence and factually incorrect. It was argued that the respondent/complainant never sustained fever due to typhoid, instead the fever caused was due to the diagnosed condition of Pansinusitis B/L Nasal polyps. By raising the aforesaid argument, it was prayed that appeal be allowed and the impugned order passed by the Forum be set aside.

7.             After going through the evidence on record and submissions of the Counsel for the appellants/opposite parties No.1 to 4, we are of the opinion that the appeal is liable to be dismissed, at the preliminary stage, for the reasons to be recorded hereinafter. The core questions, which need determination by us in this appeal is whether the appellants/opposite parties No.1 to 4 were right in repudiating the claim of the respondent/complainant or whether the Forum was right in allowing the complaint vide the impugned order by holding the said repudiation to be an unfair trade practice on the part of the appellants/opposite parties No.1 to 4. No doubt, the respondent/complainant was hospitalized in opposite party No.5 – Hospital for the period from 13.2.2018 to 16.2.2018, where he was treated for Typhoid and discharged on 16.2.2018. Medical Health Insurance policy i.e. ‘Easy Health Floater Standard’ (Annexure C-1) was valid for the period from 28.2.2017 to 27.2.2018. The respondent/complainant lodged medical claim for reimbursement of Rs.44,820/- on 19.2.2018, which the appellants/opposite parties No.1 to 4 repudiated  vide letter dated 22.2.2018 (Annexure C-8). The only ground for repudiation of the claim was that since the complainant was diagnosed of Pansinusitis with Nasal Polyp., therefore, his treatment was excluded from the Policy if admitted in 2 years of policy inception date. 

8.             However, careful perusal of the history of illness, the course of treatment undergone by the respondent/complainant at opposite party No.5 – Hospital and the certificate issued by the treating doctor, as extracted in Paras 9 & 10 of the impugned order passed by the Forum, makes it very clear that the respondent/ complainant was admitted with a provisional diagnosis of enteric fever, for which, he was given treatment and there was no other associated symptoms. He was given Injection Ceftriaxone for the said fever but during his hospitalization, he developed ear pain, for which, ET workup done, which revealed bilateral Nasal Polyps with Pansinusits. As such, it was only during the course of treatment that he was diagnosed with B/L Nasal Polyps Pansinusitis. However, his other reports for Blood culture, Malaria Antigen, Dengue Serology were negative. The fever of the respondent/complainant was duly cured with the help of antibiotics and he was discharged with an advice for further follow up in ENT OPD. It is further revealed that for B/L nasal polyps with pansinusitis, he was advised surgery by ENT surgeon. Thus, it is proved beyond doubt that the respondent/complainant was treated for enteric fever/typhoid and not for B/L nasal polyps with pansinusitis. For the said ailment, he was advised for follow-up in the ENT OPD. The claim lodged was also qua the treatment undergone i.e. enteric fever/typhoid and not for B/L nasal polyps with pansinusitis. Accordingly, we are in agreement to the view expressed by the Forum that the rejection of claim on the ground of treatment, in question, not excluded from the Policy if admitted in 2 years of policy inception date, was not sustainable. Further the Forum in Paras 12 & 13 of its order, rightly held as under:-

“12]      The OPs No.1 to 4 though claimed that the claim was duly investigated by their inhouse doctor, but failed to brought forward the affidavit of the doctor concerned, who wrongly investigated the documents including Discharge Summary submitted by the complainant along with claim.  Surprisingly, the OPs No.1 to 4 also overlooked the certificate so issued by the treating doctor Dr.Ashish Arora (Ann.R-4), which evidents that the complainant was treated for Typhoid fever only, though was also diagnosed with Bilateral Nasal Polyps with Pansinusitis.  This intentional overlooking of the documents reflects not only the highhandedness of the present Insurance Company, but also sounds that the Insurance Companies are only there to enrich their coffers by getting hefty premiums from the gullible consumers with dishonest intentions to reject even the genuine claims.  This dishonest motive to get the premiums only with deceitful intention to reject the genuine claims clearly amounts to misappropriation of public money.  In order to highlight the callous attitude of the Opposite Parties No.1 to 4 in the present complaint also, we would like to reproduce the relevant part of Para No.3 of the reply filed by OP No.5/Paras Bliss Hospital, where the complainant got treatment for Typhoid fever, which does not fall under any of the exclusion clause of the policy in question.  The relevant para is reproduced as under:-

 ‘That the complainant approached the answering-Hospital on 13.2.2018 with complaint of high fever which was diagnosed as Typhoid by the expert doctors attending the complainant.  During further investigation, the answering-Hospital detected another problem known as ‘Bilateral Nasal Polyps’ but the complainant did not go ahead with the treatment as the insurance company refused to provide cashless facility.  The complainant was ultimately discharged on 16.2.2.108 after treatment of Typhoid.  For ‘Bilateral Nasal Polyps’ the complainant was advised to follow up with ENT OPD.’  

 13]    From the above reply of Opposite Party No.5, it is quite clear that no treatment for Bilateral Nasal Polyps was taken by the complainant, which further corroborates that OPs No.1 to 4 illegally rejected the genuine claim of the complainant, adopting unfair trade practice besides rendering deficient services towards the complainant, which warrants imposing of penalty upon the OPs, in order to deter insurance companies like OPs for resorting to unfair trade practice with further caution to process and appreciate the genuine claims of the claimants adopting right perspective.”

9.             In view of above discussion, we do not find any fault with the well reasoned order of the Forum. The appellants/opposite parties No.1 to 4 have taken doctor's certificate/report as gospel truth and repudiated the mediclaim of the respondent/complainant without making any endeavour to prove their case by way of legal evidence that the respondent/complainant took any treatment for the said disease i.e. B/L nasal polyps with pansinusitis. Such a propensity and tendency on the part of the Insurance Companies needs to be curbed with heavy hand as invariably every mediclaim is being repudiated on these excuses. On the one hand, the Insurance Companies want to augment their business by charging the premium and when out of ten, one or two consumers file a claim, they start finding out one excuse or the other, most of which are dubious and feeble to defeat the rightful claim of the party. This is highly unethical and uncouth practice. We have considered this case in its entirety and hold that the appellants/opposite parties No.1 to 4 adopted unfair trade practice by arbitrarily repudiating the genuine mediclaim of the respondent/complainant. We, therefore, affirm the view held by the Forum that the appellants/opposite parties No.1 to 4 are liable to pay the claim amount to the respondent/complainant.

10.           Hence, we are of the opinion that the order passed by the Forum, being based on the correct appreciation of evidence and law, on the point, does not suffer from any illegality or perversity.

11.           No other point was raised by the Counsel for the appellants.

12.           For the reasons recorded above, this appeal being devoid of any merit, is dismissed in limine, with no order as to costs. The impugned order passed by the District Forum is upheld. Consequently, in view of dismissal of appeal, the application for condonation of delay in filing the instant appeal stands dismissed having been rendered infructuous.

13.           Certified copies of the order be sent to the parties free of charge.

14.           File be consigned to the Record Room after completion.

Pronounced

11.02.2019.

[JUSTICE JASBIR SINGH (RETD.)]

PRESIDENT

 

 

 

(PADMA PANDEY)

MEMBER

 

 

 

(RAJESH K. ARYA)

MEMBER

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