Chandigarh

DF-II

CC/125/2016

Manjit Singh - Complainant(s)

Versus

M/s Apollo Munich Health Insurance Company Ltd., - Opp.Party(s)

Y.P. Singla, Adv.

08 Dec 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

============

Consumer Complaint  No	:	125 of 2016
Date  of  Institution	:	06.01.2016
Date   of   Decision	:	08.12.2016

 

 

 

 

Manjit Singh aged about 46 years s/o Sh.Atma Singh Bajwa, R/o H.No.499/9, Baba Deep Singh Colony, Landran Road, Kharar, Tehsil Kharar, District SAS Nagar, Mohali.

 

             …………..Complainant

 

Versus

 

M/s Apollo Munich Health Insurance Company Ltd., SCO No.50-51, 4^th Floor, Sector 34-A, Chandigarh. 

 

 

 …………… Opposite Party

 

BEFORE:  SH. RAJAN DEWAN           PRESIDENT

                                MRS. PRITI MALHOTRA       MEMBER

SH.RAVINDER SINGH          MEMBER

           

 

Argued By: Sh.Y.P.Singla, Counsel for the complainant.

Ms.Manu Loona, Proxy Counsel for Sh.Nitin Thatai, Counsel for the OPs.

 

 

PER RAVINDER SINGH, MEMBER

 

                                 As per facts in issue, the complainant availed medical insurance policy, initially from Star Health and Allied Insurance Ltd. for one year w.e.f. 23.11.2012 to 22.11.2013, which was port with Apollo Munich Health Insurance Co. Ltd./OP in the year 2013 and on 18.11.2013, the OP issued a cashless insurance policy to the complainant bearing NO.110300/11121/6000135666 under Schedule-Optima Restore Insurance Policy with an insurance coverage of Rs.3.00 lacs for one year w.e.f 23.11.2013 to 22.11.2014 after receiving insurance premium of Rs.12,270/-, which was further renewed from 25.11.2014 till 24.11.2015 on receiving insurance premium of Rs.12,116.91. Under the said policy, the complainant, his wife and two daughters were covered. 

         It is submitted that the wife of complainant-Arvinder Kaur suffered from excessive bleeding and on being examined at Max Super Specialty Hospital, Mohali on 10.1.2015, she was diagnosed to be a case of Menorrhagia since 1 year for TLH and when her condition worsened, she was advised for Total Laparoscopic Hysterectomy (TLH).  For the said treatment, the complainant sought pre-approval from Opposite Party for cashless surgery (TLH) to be performed on 27.5.2015 against which the Opposite Party vide letter dated 14.5.2015 approved the initial cashless approval for Rs.45,000/-.  The wife of the complainant remained admitted in Max Super Specialty Hospital, Mohali from 27.5.2015 to 29.5.2015 and a bill of Rs.88,243/- was raised, which was submitted to the Opposite Party, who raised some queries vide letter dated 17.6.2015 and the same were duly replied vide letter dated 19.6.2015 along with treatment record of his wife of 2008 of Dogra Nursing Home & Endoscopy Centre, Chandigarh, informing the OP that although the doctor recommended them for D & C (cleaning process), as per the prescription slip dated 31.10.2013 of Liberty Hospital, Mohali, but they had never taken the treatment of D & C at that time.  However, the claim of the complainant was rejected by the OP Company on the ground that wife of the complainant is known case of ‘fibroid uterus and left ovarian cyst’ since Oct., 2013 i.e. before the policy inception and said material fact was not disclosed to the OP Company at the time of proposing for the policy, so the claim was repudiated due to non-disclosure and concealment of facts. The complainant also made representation to the Opposite Party clarifying the whole issue, but the Opposite Party vide letter dated 2.7.2015 informed that the claim is not payable under the policy. 

 

2]       The Opposite Party in its reply stated that though the policy was ported from Star Health and Allied Insurance Ltd., this cannot be considered as substitute for declaration by the proposer about diagnosed medical conditions in the proposal form and even if, the OP received a portability request, still the proposer has to fill in all the correct medical details in the proposal form.  It is also stated that the pre-existing disease from which Smt.Arvinder Kaur was suffering i.e. fibroid uterus and left ovarian cyst since Oct., 2013, was not disclosed by the complainant in the proposal form filled by him on 18.11.2013.  It is further submitted that the issuance of authorization of cashless treatment for a sum of Rs.45000/- does not in any way implies that the Opposite Party has waived the exclusions in any way.  It is submitted that the claim of the complainant was rightly rejected by the OP on the ground that she is a known case of fibroid uterus and left Ovarian Cysts since October, 2013 and had also undertaken surgery in 2008, as stated in the discharge summary, before the policy inception and because of the fact that material facts with regard to the insured member’s health conditions were not disclosed to the Opposite Party at the time of application for health insurance. Denying rest of allegations and pleading no deficiency in service, the Opposite Party has prayed for dismissal of the complaint.

 

3]       The complainant also filed replication reiterating contentions as raised in the complaint.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have examined the entire evidence & documents on record thoroughly.

 

6]       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

 

7]       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.

 

8]       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.  

 

9]       From the careful examination of the above facts, it transpires that the complainant has not violated any terms & conditions of the medical insurance policy and is entitled for the claim of Rs.88,243/- on account of medical treatment of his wife Smt.Arvinder Kaur. 

 

10]      Keeping in view the above facts, the complaint is allowed and the Opposite Party is directed to reimburse the medical claim of Rs.88,243/-  to the complainant within a period of 30 days from the date of receipt of certified copy of this order. 

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

8^th December, 2016                          Sd/-

(RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER