Punjab

Ludhiana

CC/14/570

Parveen Vij - Complainant(s)

Versus

M/s Apollo Munich Health Ins.Co.Ltd - Opp.Party(s)

Surinder Singh

23 Feb 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

                                                                 Complaint No: 570 of 20.08.2014

                                                                                                                    Date of Decision: 23.02.2015

                                                                                                                   

Parveen Vij aged 45 years s/o Sh.Bharat Bhushan Vij resident of H.No.B-XXXIV-2605, Rajesh Nagar, Near Naseeb Enclave Haibowal Kalan, Ludhiana.

Alternative Address:-

Resident of H.No.2605, New Tagore Nagar, Ludhiana.

……Complainant

Versus 

1. M/s Apollo Munich Health Insurance Co. Ltd., S.C.O. 146, 2^nd Floor, Feroze Gandhi Market, Ludhiana, through its Branch Manager.

2. M/s Apollo Munich Health Insurance Company Ltd., 10^th Floor, Building no.10, Tower-B DLF City, Phase-2, Gurgaon (Haryana)-122002, through its Managing Director/General Manager/Principal Officer.

 

…..Opposite parties 

 

COMPLAINT UNDER SECTION 12 OF THE

CONSUMER PROTECTION ACT, 1986.

 

Quorum:     Sh.R.L.Ahuja, President

                   Sh.Sat Paul Garg, Member

                   Smt.Babita, Member

 

Present:       Sh.Surinder Singh Khakh, Adv. for complainant.

                   Sh.Ajay Chawla, Advocate for OPs.  

 

                   

                        ORDER

 

(SAT PAUL GARG, MEMBER)

 

 

1.               Present complaint under Section 12 of The Consumer Protection Act, 1986 (herein-after in short to be referred as ‘Act’) has been filed by Sh.Parveen Vij s/o Sh.Bharat Bhushan Vij r/o H.No.B-XXXIV-2605, Rajesh Nagar, Near Naseeb Enclave Haibowal Kalan, Ludhiana (herein-after in short to be referred as ‘complainant’) against M/s Apollo Munich Health Insurance Co. Ltd., S.C.O. 146, 2^nd Floor, Feroze Gandhi Market, Ludhiana, through its Branch Manager and others (herein-after in short to be referred as ‘OPs’)- directing them to pay Rs.34,630/- alongwith compensation of Rs.50,000/- towards damages alongwith interest @ 12% to the complainant or also any further relief to which the complainant may be found entitled.

2.                Brief facts of the complaint are that the representative of OP1 approached the complainant on December, 2010 and induced him to buy Health Insurance policy, which would provide risks of ailments, hospitalization. Believing the said representation, the complainant purchased first policy on December 14, 2010 for the first time for his whole family and the premium of Rs.6938.98 was paid which cover the risk upto December 19, 2011. Later on it was timely renewed and lastly policy was renewed for his whole family bearing policy no.10600/11108/1000140463-02 dated December 24, 2013 and paid an amount of Rs.15,243/- towards premium. The said policy covered the aforesaid risks from December 2013 to 19 December 2015 and the premium of Rs.15,423/- was paid against receipt to the insurance company. The complainant was feeling weakness reducing weight and feeling restless sleep from the last one month and he approached Fortis Hospital, Ludhiana. Due to the weakness he was hospitalized on May 24, 2014 in Fortis Hospital, Chandigarh Road, Ludhiana. The complainant informed the concerned official of the OPs on phone about his hospitalization on the same day of his admission in the hospital. During the course of hospitalization the complainant had to incur an amount of Rs.34,630/- on his treatment. Afte discharge from the hospital complainant submitted a claim of Rs.34,630/- with the OPs alongwith documents. But the Ops vide letter dated 26.6.14 repudiated the claim of the complainant on the ground that claim for Generalized Anxiety Disorder falls under Psychiatric /Mental/Genetic disorder, which is excluded in the policy. The repudiation of the claim of the complainant by the Ops is illegal null and void and against the principles of justice. Claiming the above act as deficiency in service on the part of the OPs, the complainant has filed this complaint.

3.                On notice of the complaint, OPs appeared through their counsel and filed written statement taking preliminary objections that at the very outset denied all the allegations, facts and averment stated in the complaint; the complaint is not maintainable and is liable to be dismissed and no cause of action ever arose in favour of the complainant and against the OPs to file the present complaint. Further submitted that complainant (Parveen Vij) “Life Assured” (herein after referred to as LA) had submitted the duly filled and signed proposal/application dated 13.12.10 for the purchase of Easy Health Individual Standard Plan from Apollo Munich Health Insurance Company, the proposal was accepted on the standard rates based on the information provided by the LA and consequently a policy was issued bearing policy no.110600/11001/1000140463 dated 20.12.10 and the same commenced on 20.12.10. The premium @ Rs.6938/- was paid for one year which was renewed vide policy no.110600/11001/1000140463-01 till 19.12.13 and further renewed vide policy no.110600/11001/1000140463-02 till 19.12.15. The present complaint is an afterthought and has only been filed with ulterior motives to harass and humiliate the OPs. Further stated that the OPs received cashless request on 24.5.14 from the Fortis Hospital Ludhiana for patient Parveen Vij (complainant), who got admitted with c/o Gen. Weakness, Wt. loss X 30 days with probable diagnosis of thyrotoxicosis with D.O.A 24.5.14 and estimated cost of Rs.38,500/- and estimated duration of stay of two days. On post reviewing the documents, additional information was raised on 24.5.14 stating that “Please forward the investigation reports of the patient supporting the diagnosis with the treatment charts and vita charts. Kindly provide treating doctors certificate for post h/o Thyrotoxicosis. Also forward the first consultation prescription related to diagnosis of Thyrotoxicosis. All past treatment records. Or all relevant investigation reports in support of diagnosis”. OPs when have not received any reply then on 25.5.14 a reminder was again sent but again no reply was received, due to which again on 26.5.14 another reminder was sent and on 26.5.14 on final reminder was also sent. The hospital sent a reply which was insufficient and not as per the query  raised by the OPs, due to which again final reminder was sent on 27.5.14 against which the documents were received from the client against which an initial approval of Rs.20,000/- was given on 27.5.14. On 28.5.14 the hospital sent the medical documents which were received for final approval and post reviewing the said documents particularly the progress note dated 24.5.14 which clearly stated that ‘complainant was admitted for investigation’ only. Hence, the cashless was rejected on 28.5.14 stating that ‘Cashless facility cannot be granted as patient is admitted primarily for investigation and evaluation only. However insured can file the claim for reimbursement post completion of the treatment with all medical and financial records. The admissibility of the claim would be decided post review of the documents and policy conditions. Note- Anxiety treatment is not covered in our policy. Previous authorization also stands cancelled.”. On merits, denied the contents of other remaining paras, OPs prayed for dismissal of the complaint.

4.                Ld. counsel for complainant has adduced the evidence by way of duly sworn affidavit of complainant Sh.Parveen Vij Ex.CA, wherein, the same facts have been reiterated as narrated in the complaint and affidavit of Dr.Karamvir Goyal, Senior Consultant and H.O.D. Fortis Hospital, Ludhiana Ex.CB and also attached documents Ex.C1 to Ex.C6. On the other hand, Ld. counsel for Ops has adduced the evidence by way of duly sworn affidavit of Srikanth Kandikonda Ex.RA, wherein, the same facts have been reiterated as narrated in the written statement specifically deposing that in the Discharge Summary it’s specifically mention in the diagnosis as “Generalized Anxiety Disorder” and it is pertinent to mention that Anxiety disorders are common psychiatric disorders and excluded in the Policy Terms and Conditions under Section VI (C) (vi) (j). That the present complaint is thus presented, ridden with allegations of deficiency in service and unfair trade practices, but the present complaint miserably fails to co-relate the facts and incidents in order to prove any deficiency in service and unfair trade practice. Complainant fails to prove any act as alleged in the whole of the complaint that points out any deficiency in service and unfair trade practice on the part of the OPs. Further deposed that the OP had rejected the claim of the complainant under section VI C vi J of the policy, which read as under:-

j. Psychiatric, mental disorders (including mental health treatments), Parklnson and Alzhelmer’s disease, general debility or exhaustion (“run down condition) sleep-apnoea”

 

          Ld. counsel for Ops also placed on record documents Ex.R1 to Ex.R20.

 

5.                Case was fixed for arguments. Ld. counsel for complainant filed written arguments, whereby it is averred that the complainant availed health insurance policy to cover the risk of hospitalization and the policy was purchased by the complainant for the first time for the whole family. Later on it was timely renewed for the period from December 24, 2013 to 19, December 2015. The complainant was hospitalized for general weakness and he approached Fortis Hospital, Ludhiana, where he remained admitted from 24 May 2014. Duly signed consent form Ex.C3 was sent to office and thereafter the complainant got proper treatment from the said hospital and paid Rs.34,630/- as medical expenses including tests and medicines. Ops sent letter to the complainant dated 26.6.14 that the claim for the Generalized Anxiety Disorder falls under Psychiatric /Mental/Genetic disorder is excluded in the policy, so the claim has been repudiated under section VI C vi.

6.                Refuting the allegations leveled by the complainant, Ld. counsel for OPs argued orally that complainant underwent the treatment for the Generalized Anxiety Disorder, which is excluded as per exclusion clause VI C vi j, which is reproduced as under:-

“Sec. VI. Special Terms and Conditions:-

A*****

B*****

C. General exclusions:

We will not pay for any claim in respect of any insured person directly or indirectly for, caused by, arising from or in any way attributable to:

i, ii, iii, iv, v******

vi. Types of treatment, defined illnesses/conditions/supplies:

a, b, c, d, e, f, g, h, I, *******

 

j. Psychiatric, mental disorders (including mental health treatments), Parklnson and Alzhelmer’s disease, general debility or exhaustion (“run down condition) sleep-apnoea”

7.                We have gone through the pleadings and written arguments submitted on behalf of complainant as well as defence taken by the Ops.

8.                It is evident that the complainant was diagnosed for Generalized Anxiety Disorder Gall Bladder Polyp. The treatment given to him which as per the detail of the Ops as follows:-

            “Complainant was admitted for generalized weakness, loss of weight and decreased sleep, which is associated to anxiety disorder. Complainant underwent psychiatric opinion and treatment through medicine prescribed by doctors. Medicine provided to complainant was Alarm Forte (Prescribed for anxiety and panic disorders), Mecobalamm (Form of vitamin B, a Multivitamin), Biopin (Anti-Psychotic Drugs), Supanac (Anti-inflammatory drug) and Alive 22 (Multivitamin).”

 

                   It is also clear that the treatment taken by the complainant Generalized Anxiety Disorder is not covered as per exclusion clause VI C vi j of the policy. However, the patient was also suffering from Gall Bladder Polyp. Though he himself refused for the surgery of the same yet the Anti-inflammatory medicine was given to him and the same was for this very purpose i.e. for the disease Gall Bladder Polyp. This factor is neither been clarified by the complainant nor the OPs refuted, which requires further examination of the claim.

9.                In view of the above discussion, the present complaint is partly allowed and OPs are directed to re-examine the case of the complainant qua disease Gall Bladder Polyp as well as prescription of anti-inflammatory medicine and to allow, in case the complainant was treated for this very disease according to the terms and conditions of the policy. Further Ops are directed to pay Rs.3000/-(Three thousand only) as compensation and litigation expenses compositely assessed to the complainant. Order be complied within 30 days of receipt of the copy of the order, which be made available to the parties free of costs. File be consigned to record room.

 

                   (Babita)                          (S.P.Garg)                      (R.L.Ahuja)

                   Member                           Member                         President

Announced in Open Forum.

Dated:23.02.2015 

Hardeep Singh