Punjab

StateCommission

A/648/2017

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

Versus

Mohinder Pal Singh - Opp.Party(s)

Mohan Lal Singhi

30 Jan 2018

ORDER

        2^Nd ADDITIONAL BENCH

STATE  CONSUMER  DISPUTES  REDRESSAL COMMISSION, PUNJAB, CHANDIGARH.

First Appeal No. 648 of 2017

                                                          Date of Institution:  08.09.2017

                                                          Date of reserved  :17.01.2018

                                                          Date of Decision:    30.01.2018

 

Apollo Munich Health Insurance, Ist Floor, Satnam Complex, New Court Road, near Yes Bank, BMC Cowk, GT Road, Jalandhar 144001, through its Branch Manager.

 

                                                                    Appellant/opposite party

Versus

Mohinder Pal Singh s/o Sh. Balwant Singh, H. No.556, Greater Kailash, Near CT Public School, Jalandhar.

 

                                                                    Respondent/complainant

 

First Appeal against order dated 11.07.2017 passed by the District Consumer Disputes Redressal Forum,  
Jalandhar.

Quorum:-

          Shri Gurcharan Singh Saran, Presiding Judicial Member.

         Shri Rajinder Kumar Goyal, Member

Present:-

          For the appellant          :         Sh.NiteshSinghi,Advocate

          For the respondent      :         Sh. R.K. Bhatti, Advocate

         

 

RAJINDER KUMAR GOYAL MEMBER

ORDER

                   The appellant/opposite party (hereinafter referred to as OP) has filed the present appeal against the order dated 11.07.2017 passed in Consumer Complaint No.410 of 2015 by District Consumer Disputes Redressal Forum,  Jalandhar (hereinafter referred as District Forum) vide which the complaint filed by the complainant was partly accepted and OP was directed to pay the claim amounting Rs.93,251/- to the complainant along with interest @ 9% per annum from the date of repudiation of the claim i.e. 08.07.2015 till realization. OP was further directed to pay compensation of Rs.10,000/- to the complainant for mental harassment and litigation expenses of Rs.3000/-. They were directed that the entire compliance be made within one month from the date of receipt of the copy of order. 

2.                Complaint was filed by the respondent/complainant (hereinafter referred as complainant) under Consumer Protection Act, 1986 (in short, "the Act") against the OP on the averments that the complainant had taken a medical insurance policy No.180200/11001/AA002500066w.e.f. 24.02.2015 to 23.02.2016 for a sum of Rs.5,00,000/- from opposite party. Earlier the petitioner was insured with United India Insurance Company Limited for the period 27.02.2014 to 26.02.2015. The complainant was availing medical insurance since the year 2008 from various insurance companies. The OP assured and promised that the above policy would be cashless policy and the complainant paid a premium of total Rs.23,027.79. After being satisfied about the terms and conditions of the policy, OP issued the policy. The calculation of the premium was done by keeping in view earlier insurance availed by the complainant. During the subsistence of the policy the complainant suffered from ailment and was admitted to Patel Hospital, Jalandhar. The complainant approached the OP for payment of hospital expenses amounting to Rs.32,910/- to  the hospital. The OP showed helplessness and did not pay the said amount inspite of the policy being cashless. The complainant submitted all the documents on 18.06.2015 of the medical treatment after discharge from the hospital. The claim was not paid. The complainant subsequently was again admitted on 09.07.2015 on account of calculus of kidney. The said claim of Rs.60,611/- was lodged which was also not paid. The complainant’s claim was wrongly rejected. The OP rejected the claim by stating that the cashless facility cannot be granted as present ailment for which treatment is sought comes under two years exclusion list of policy terms and conditions. The complainant thereafter even submitted documents and also explained when this policy was taken. It was pointed out to the OP that the petitioner had been taking policy since 2008 and the OP was fully aware that the petitioner had been taking the policy from United India Insurance Company Limited and knowing fully well about the earlier insurance, this insurance policy was issued by the OP. The OP has adopted unfair trade practice and there is deficiency on the part of OP as the OP has failed to discharge the services efficiently. As such this complaint has been filed, and prayed to allow the complaint and Op be directed to pay as under :

1. Rs. 93521/- on account of treatment charges.
2. Rs.50,000/- on account of damages and deficiency in service.
3. Rs.1000/- Litigation charges.
4. Interest @ 15% per annum from the date of commencement of the medical treatment.

3.                Upon notice, OP appeared through his counsel and contested the complaint by taking preliminary objections that prima facie no cause of action has arisen in favour of the complainant to file the present complaint as ailment for which claim facility was claimed fall under the waiting period clause of the policy hence no benefit can be given to the complainant. It was further submitted that the complainant raised two reimbursement claims with the OP and both the claims were due to illness and treatments related to calculus disease of urogenital system, the rejection of both the claims is as per terms and conditions of the policy, therefore, there is no unfair trade practice or deficiency in service on the part of OP. In the proposal form and also during the medical examination the complainant had not mentioned any past medical history.However, in the present medical documents submitted by the complainant himself it is revealed that the complainant had a past surgical history of renal stone six years back and this clearly amounts to a non-disclosure on the part of the complainant himself and without prejudice to the present claim, the company is at liberty to terminate the policy of the complainant. On merits, the purchase of the policy from OP by the complainant is admitted but all other allegations were categorically denied and lastly submitted that the claim was rejected strictly according to  the policy terms and conditions. The complaint is without merit and the same be dismissed.

4.                Before the District Forum the parties were allowed to lead their respective evidence.

5.             In support of his allegations, the counsel for the complainant tendered into evidence the affidavitas Ex.CW-1/A and some documents Ex.C-1 to Ex.C-16 and closed the same on behalf of the complainant. In rebuttal the counsel for the OP had tendered into evidence affidavit Ex.OPA along with some documents i.e. power of attorney Ex.OP-1, proposal Forum Ex.OP-2, portability form along with terms and conditions (consisting of 24 pages) Ex.OP-4, pre-authorization form along with documents
(consisting of 6 pages) Ex.OP-5, Claim form along with documents including rejection letter dated 03.07.2015 Ex.OP-6, claim form along with documents and rejection letter dated 03.08.2015 Ex.OP-7 and closed the evidence on behalf of the OPs.

6.                After going through the allegations as alleged in the complaint, written version filed by OP, evidence and documents brought on record, the complaint filed by the complainant was accepted.

7.                Aggrieved with the order passed by the District Forum, the appellant/opposite party has filed the present appeal.

8.                We have heard the learned counsel for the parties.

9.                Counsel for the appellant argued that the complainant for availing medical insurance policy submitted a proposal form (Ex.OP-2) wherein provided information of his previous insurance policies in para No.5 giving details of policy from the United India Insurance Company Limited,policy for the period form 27.02.2014 to 26.02.2015 i.e. for one year. The complainant neither mentioned that he is insured since 2008 nor do any such policy documents were submitted to the OP. The complainant submitted a portability form (Annexure A-2) along with the proposal form and in that complainant also shared details of previous insurance policy. Based upon the declaration, information and details provided by the complainant, policy was issued by OP valid from 27.02.2015 to 26.02.2016. The complainant had never raised any objection within the free lock period under the policy after receiving the policy documents. As such the complainant is strictly bound by the terms and conditions of the policy. It was further  argued that the complainant submitted two reimbursement claims and both  the claims were due to illness and treatments related to calculus disease of urogenital system which  are covered under the waiting period of two years as per Section VI. Special terms and conditions, ii(e) of the Policy. As the insurance policy was from 27.02.2014 to 26.02.2016 and the claims were submitted on 22.06.2015 and 17.07.2015 i.e. less than two years period. Hence the rejection of both  the claims is as per terms and conditions of the policy. There is no deficiency in service and negligence or unfair trade practice as alleged. The repudiation of the claim was sent by the OP to the complainant as per Ex.OP-5. The District Forum had wrongly and illegally accepted the complaint which is against the terms and conditions of the policy and the same is not sustainable in the eyes of law.  The counsel further argued that the impugned order is non-speaking order and prayed to accept the appeal and set aside the order of the District Forum in CC No.410 of 2015 in the interest of justice.

10.              Counsel for the respondent No.1/complainant argued that the complainant was regularly insured since the year 2008. The calculation of premium was also done keeping in view the earlier insurance availed by the complainant. The complainant submitted all the documents of medical treatment along with relevant bills after the discharge from the hospital but the OP rejected the claim stating that cashless facility cannot be granted as present ailment for which treatment was sought comes under two years exclusion list of policy terms and conditions. The policy start date was taken by the OP as 27.02.2015 and only due to this contention the claim was rejected. The counsel further argued that there is a deficiency in service on the part of OPs. The District Forum has rightly accepted the complaint wherein OP was directed to pay the claim amount along with interest, compensation and litigation expenses. The appeal may please be dismissed and the order of the District Forum be upheld.

11.              From the above, it is evidenct that the OP issued a  medical insurance policy w.e.f. 27.02.2015 to 26.02.2016 on the basis of proposal/portability form submitted by the complainant wherein the complainant declared that he was having previous insurance policy from United India Insurance Company w.e.f. 27.02.2014 to 26.02.2015. There is no evidence to show that the complainant was regularly  insured with other insurance companies w.e.f. 2008. The complainant after medical treatment in Patel Hospital Jalandhar submitted two claims on 22.06.2015 and 17.07.2015 as per claim forms Ex.C-13 & Ex.C-15 wherein ‘calculus of kidney ureter’ has been mentioned under the details of hospitalization. As per terms and conditions of the policy under-A waiting period which is reproduced as below:-

          i)       We are not liable for any claim arising due to treatment and admission within 30 days from policy commencement Date Except claims arising due to an accident.

          ii)      A waiting period of 24 months from policy commencment date shall apply to  the treatment, whether medical or surgical, of the disease/conditions mentioned below. Additionaly the 24 months waiting period shall also be applicable to  the surgical procedures mentioned under surgeries in the following table, irrespective of the disease/condition for which the surgery is done, except claims payable due to the occurrence of canner.  

Sr. No.	Oran/Organ System	Illnes	Treatment
E	Urogenital	Calculus disease of urogenital system Example: Kidney stone, urinary bladder stone. Begign Hyperplasia of prostate	Surgery on prostate Surgery for Hydrocele/Rectocele

          From above calculus diseases of urogenital system has a waiting period of two years from the policy commencement which was 27.02.2014 as per the evidence. As the claims submitted by the complainant were less than two years waiting period the rejection is within the policy terms and conditions. The complainant has not denied the terms and conditions of the policy in his complaint.

12.              We are also supported by the judgment of the Hon’ble Apex Court of India in the case of Suraj Mal Ram Niwas Oil Mills Pvt. Ltd., vs. United India Insurance Company and another (2011 (1) CLT 458), that “ Contract of insurance- Construction of contract of insurance- in construing the terms of a contract of insurance, the words used therein must be given paramount importance- it is not open for court to add, delete or substitute any words- the endeavor of the Court should always be to interpret the words in which the contract is expressed by the parties”.The District Forum has failed to appreciate the terms and conditions of the policy. The plea taken by the District Forum that the policy has been obtained by the complainant for one year i.e. from 27.02.2015 to 26.02.2016 and two years period will not come during the subsistence of that policy, obtained by the complainant, if so, then what will be the use for the complainant to get the policy, so these terms and conditions itself prove to be vague and not legal and binding upon the complainant, is not with the perview of the District Forum being contrary to the terms and conditions of the Insurance Policy Contract binding upon both  the parties.

13.              Sequel to the above discussion, we accept the appeal and the order of the District Forum is set aside. The complaint is hereby dismissed.

14.               The appellant had deposited an amount of Rs.25000/- with this Commission at the time of filing the appeal. This amount with interest accrued thereon, if any, be remitted by the registry to the concerned District Forum, after the expiry of 90 days, from the dispatch of the certified copy of the order to the parties; subject to stay, if any, by the higher Fora/Court for release of the above amount and the District Forum may pass the appropriate order in this regard.  

15.              The appeal could not be decided within the statutory period due to heavy pendency of the Court cases.

16.              Copy of the order be communicated to the parties as per rules. 

                                                                     (Gurcharan Singh Saran)

                                                                   Presiding Judicial Member

 

                                                                  

January  30,2018                                    (Rajinder Kumar Goyal)

PK/-                                                                     Member