STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
U.T., CHANDIGARH
Appeal No. | : | 46 of 2017 |
Date of Institution | : | 09.03.2017 |
Date of Decision | : | 12.05.2017 |
M/s Apollo Munich Health Insurance Company Ltd., SCO No.50-51, 4th Floor, Sector 34-A, Chandigarh, through Ms. Deepti Rustagi, Vice President-Legal & Compliance
……Appellant
V e r s u s
Manjit Singh son of Sh.Atma Singh Bajwa, R/o H.No.499/9, Baba Deep Singh Colony, Landran Road, Kharar, Tehsil Kharar, District SAS Nagar, Mohali.
...Respondent
Appeal under Section 15 of the Consumer Protection Act,
1986 against order dated 08.12.2016 passed by District Consumer Disputes Redressal Forum-II, U.T.Chandigarh in Consumer Complaint No.125/2016.
Argued by: Mr. S.C.Thatai, Advocate for the appellant.
Mr. Y.P.Singla, Advocate for the respondent.
Appeal No. | : | 40 of 2017 |
Date of Institution | : | 03.03.2017 |
Date of Decision | : | 12.05.2017 |
Manjit Singh, aged about 47 years, son of Sh.Atma Singh Bajwa, R/o H.No.499/9, Baba Deep Singh Colony, Landran Road, Kharar, Tehsil Kharar, District SAS Nagar, Mohali.
-Appellant
V e r s u s
M/s Apollo Munich Health Insurance Company Ltd., SCO No.50-51, 4th Floor, Sector 34-A, Chandigarh, through its Branch Manager
..Respondent
Appeal under Section 15 of the Consumer Protection Act,
1986 against order dated 08.12.2016 passed by District Consumer Disputes Redressal Forum-II, U.T.Chandigarh in Consumer Complaint No.125/2016..
Argued by: Mr. Y.P.Singla, Advocate for the appellant
Mr. S.C.Thatai, Advocate for the respondent.
BEFORE: JUSTICE JASBIR SINGH (RETD.), PRESIDENT. MR.DEV RAJ, MEMBER
MRS. PADMA PANDEY, MEMBER
PER JUSTICE JASBIR SINGH (RETD.), PRESIDENT
This order will dispose of aforementioned two appeals bearing No.46 of 2017 titled as Apollo Munich Health Insurance Co. Ltd. Vs Manjit Singh and counter appeal bearing No. 40 of 2017 titled as Manjit Singh Vs Apollo Munich Health Insurance Co. Ltd., both filed against judgment dated 8.12.2016 passed by the District Consumer Disputes Redressal Forum-II, U.T.Chandigarh (for short ‘the Forum’ only) allowing consumer complaint bearing No.125 of 2016 filed by respondent/complainant (appellant in Appeal No.40 of 2017). To dictate order, the facts are being taken from appeal No.46 of 2017 titled as Apollo Munich Health Insurance Co. Ltd. Vs Manjit Singh.
2.. Before the Forum, it was case of the complainant that he, alongwith his family members, purchased one health insurance policy from Star Health and Allied Insurance Ltd. for one year i.e. between 23.11.2012 to 22.11.2013. The said policy was ported with the appellant/OP in the year 2013 and the OP issued fresh insurance policy bearing No.1103300/11121/6000135666-01 under Schedule-Optima Restore Floater Policy with an insurance coverage of Rs.3 lacs. The policy was valid for one year i.e. between 23.11.2013 to 22.11.2014. The respondent/complainant paid the premium of Rs.12270/- for the said period. The policy was further extended for the period falling between 25.11.2014 to 24.11.2015 against payment of premium of Rs.13116.91. It is necessary to mention here that as per terms and conditions of the said policy, the complainant, his wife and two daughters were covered.
As per facts on record, wife of the complainant namely Arvinder Kaur suffered from excess bleeding. She went to Max Super Specialty Hospital, Mohali on 10.1.2015. She was diagnosed to be a case of Menorrhagia for the last one year. Her condition worsened. She was suggested Total Laparoscopic Hysterectomy (TLH) for the said treatment. The complainant sought pre-approval from the OP for cashless surgery (TLH) to be performed on 27.5.2015. The appellant/OP gave its consent vide letter dated 14.5.2015 limiting initial cashless approval upto Rs.45,000/-. After surgery, wife of the complainant remained in the hospital upto 29.5.2015. The hospital raised a bill for an amount Rs.88,243/- . The said bill was sent to the OP for reimbursement. Some queries were raised, which were replied alonwith treatment record of wife of the complainant w.e.f. 2008. It was specifically stated that though on 3.10.2013, the doctor in Liberty Hospital, Mohali, had recommended for cleaning process(D&C), however, wife of the complainant had not undergone the said treatment. The complainant was intimated vide letter dated 29.6.2015 stating that as his wife was a known case of ‘fibroid uterus and left ovarian cyst’ w.e.f. October,2013, the policy was liable to be terminated and in case his concurrence is not communicated within 7 days of receipt of the said letter, termination endorsement shall be issued. The complainant took up the matter with the OP by making a representation, however, vide letter dated 2.7.2015, the OP repudiated the claim on account of non-disclosure and concealment of facts under Section 5 u of policy terms and conditions.
3. Upon notice, reply was filed by the appellant/OP. Issuance of policy in the manner, as referred to above, was admitted. It was only said that when the complainant got insurance policy issued through OP, he failed to disclose the material fact of his wife’s suffering from above said disease in the proposal form filled on 18.11.2013.
4. Both the Parties led evidence. The Forum, on analysis of pleadings of the parties, evidence on record, and the arguments addressed, partly allowed the complaint. It was held that the complainant was entitled to reimbursement of claim amount of medical bill i.e. Rs.88,243/- which was spent on the treatment of his wife. Awarded amount was ordered to be paid within a fixed period. It is necessary to mention here that neither interest, nor compensation for physical and mental harassment was awarded, which led the complainant to file appeal bearing No.40 of 2017, claiming relief to that extent.
5. Counsel for the appellant has vehemently contended that when proposal form was filled up to get the policy, material fact of pre-existing disease, from which wife of the complainant was suffering, was not disclosed and on that basis claim was rightly rejected by the appellant. Similar contention was raised by the appellant before the Forum. The Forum when granting relief in favour of the complainant rejected the said contention by observing
as under ;
“The complainant took medical insurance policy from Star Health and Allied Insurance Ltd., which was effective from 23.11.2012 to 22.11.2013. He, however, switched over to Optima Restore Insurance Policy of Apollo Munich health Insurance Company, which was valid with effect from 23.11.2013 to 22.11.2014 and then renewed from 25.11.2014 to 24.11.2015 for an amount of Rs.3.00 lacs and covered the following:-
1.Mrs.Manjit Singh Self
2.Mrs.Arvinder Kaur Wife
3.Miss Arshpreet Kaur Daughter
4.Baby Sargun Bajwa Daughter
The policy under Star Health and Allied Insurance Ltd., was given due consideration for portability benefits, including bonus etc. Smt.Arvinder Kaur wife of the complainant was diagnosed for the disease of Menorrhagia and advised Total Laparoscopic Hysterectomy (TLH). She was operated at Max Super Specialty Hospital, Mohali on 27.5.2015 and was discharged on 29.5.2015. M/s Apollo Munich health Insurance Company/Opposite Party vide its letter dated 14.5.2015 (Ann.C-8) considering the case of the complainant regarding the treatment of Smt.Arvinder Kaur, accorded approval for surgical management/treatment for an amount of Rs.45,000/-. However, after discharge of Smt.Arvinder Kaur, the claim of the complainant for reimbursement of a total expenditure of Rs.88,243/- was rejected vide letter dated 2.7.2015 (An.C-18) without affording an opportunity of hearing/defence to the complainant before repudiating his claim and did not even issue any Show Cause Notice to Smt.Arvinder Kaur, who is the principal beneficiary under the insurance policy, which is in utter violation of principle of audi alteram partem that no one can be condemned unheard. The order of repudiation of claim as conveyed vide letter dated 2.7.2015 by Opposite Party suffers from procedural impropriety and basic principle of natural justice.
Smt.Arvinder Kaur had medical insurance with effect from 23.11.2012 and fallen sick and operated upon on 27.5.2015 i.e. after 30 month’s period from the date of taking the medical insurance policy. There is no impediment in grant of insurance claim in the present case as per Health Insurance Policy applicable in the present case. Smt.Arvinder Kaur admittedly has taken some treatment on 18.11.2013 from Liberty Hospital, Mohali due to excessive bleeding on account of gynecological problem, but she was covered by the medical insurance policy from Star Health and Allies Insurance Ltd., which has been duly considered and permitted for the purpose of portability while opting to the medical insurance Optima Restore Insurance Policy by Apollo Munich Health Insurance Company Ltd. As per record, Smt.Arvinder Kaur had medical insurance w.e.f. 23.11.2012 to 24.11.2015, but she preferred no claim except this present claim of Rs.88,243/- for the surgical treatment, which was compulsive and cannot be termed to be a luxury.”
6. It was rightly noticed that there was no question of non-disclosure of pre-existing disease, as stated. It was further said that the policy was taken on 23.11.2012, it was ported with the appellant in the year 2013. Wife of the complainant was operated upon on 27.5.2015 i.e. after a period of 30 months of taking the Health Insurance Policy. It was further noted that though wife of the complainant had taken treatment for excess menstrual bleeding on 18.11.2013 but that cannot be taken as impediment in granting relief to her.
7. We have seen the record of the Forum available with this Commission. It is on record that the claim was rejected by stating that when obtaining the Health Insurance Policy, wife of the complainant was a patient of Fibroid uterus and left ovarian cyst. To say so, reliance was placed on a document available at page 203- medical prescription slip issued by the Liberty Hospital, Mohali. We have perused the same. On its one side, it is only mentioned that she needed treatment for fibroid uterus cyst left ovary. It is nowhere mentioned that the said disease was found and any treatment was taken by the wife of the complainant, as alleged by the OP. It was a routine check-up for excess menstrual bleeding. Further, to reject the claim, neither the doctor who issued the prescription slip, nor his affidavit has been placed on record. We find no case made out to make interference in the order, under challenge, at the instance of the appellant. Accordingly appeal bearing No.46 of 2017 filed by the appellant is dismissed, with no order as to costs.
8. There is substance in appeal No.40 of 2017 filed by the appellant/complainant. It is apparent on record that when granting limited relief to the complainant, neither interest, nor compensation for physical and mental harassment was awarded by the Forum. To that extent, order passed is not justified. It is proved on record that payment of due amount was refused without any justifiable reason.
9. In view of the above, appeal bearing No.40 of 2017 is partly accepted and the respondent/OP is directed to pay interest @ 8% p.a. (simple) on the awarded amount of Rs.88243/- w.e.f. 2.7.2015, the date of rejection of his claim for reimbursement of medical expenses till the time payment is made. Further, complainant is held entitled to compensation for physical and mental harassment to the extent of Rs.15,000/-. The amount awarded by the Forum and also ordered by this Commission, be paid by OP to the complainant within 30 days from the date of receipt of certified copy of the order, failing which, awarded amount shall entail interest @ 10% p.a. (simple) from the date of passing this order till such time the payment is made.
10. Certified copy of this order, be placed on the file of Appeal bearing No.40 of 2017
11. Certified copies of this order, be sent to the parties, free of charge.
12. The file be consigned to Record Room, after completion.
Pronounced.
12.05.2017
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
U.T., CHANDIGARH
Appeal No. | : | 40 of 2017 |
Date of Institution | : | 03.03.2017 |
Date of Decision | : | 12.05.2017 |
Manjit Singh, aged about 47 years, son of Sh.Atma Singh Bajwa, R/o H.No.499/9, Baba Deep Singh Colony, Landran Road, Kharar, Tehsil Kharar, District SAS Nagar, Mohali.
-Appellant
V e r s u s
M/s Apollo Munich Health Insurance Company Ltd., SCO No.50-51, 4th Floor, Sector 34-A, Chandigarh, through its Branch Manager
..Respondent
Appeal under Section 15 of the Consumer Protection Act,
1986 against order dated 08.12.2016 passed by District Consumer Disputes Redressal Forum-II, U.T.Chandigarh in Consumer Complaint No.125/2016..
Argued by: Mr. Y.P.Singla, Advocate for the appellant
Mr. S.C.Thatai, Advocate for the respondent.
PER JUSTICE JASBIR SINGH (RETD.), PRESIDENT
Vide our separate detailed order of the even date, recorded in Appeal bearing No.46 of 2017 titled as Apollo Munich Health Insurance Co. Ltd. Vs Manjit Singh, this appeal has been partly accepted.
2. Certified copy of the order passed in Appeal bearing No. 46 of 2017, shall also be placed on this file.
3. Certified copies of this order, alongwith the main order passed in Appeal bearing No. 46 of 2017, be sent to the parties, free of charge.
4. The file be consigned to Record Room, after completion.
