Haryana

Gurgaon

cc/144/2014

Renu Rastogi - Complainant(s)

Versus

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

03 May 2016

ORDER

                                 DISTRICT   CONSUMER   DISPUTES   REDRESSAL FORUM, GURGAON-122001

                                                                                    Consumer Complaint No: 144 of 2014                                                                                                                             Date of Institution: 14.05.2014                                                                                                                                                      Date of Decision: 03.05.2016

Renu Rastogi w/o Shri Naresh Kumar aged 54 years, R/o GH-4 10C, Orchid Garden, Suncity, Sector-54, Gurgaon.

                                                                                                                                                                                                                        ……Complainant.

                                                Versus

M/s Apollo Munich Health Insurance Company Ltd, 10th Floor, Tower-B, DLF Cyber City, DLF City, Phase-II, Gurgaon through its Director/Authorized person.

                                                                                              ..Opposite party

                                                                                               

Complaint under Sections 12 & 14 of Consumer Protection Act,1986                                                                  

 

BEFORE:     SHRI SUBHASH GOYAL, PRESIDENT

SMT JYOTI SIWACH, MEMBER

                   SH.SURENDER SINGH BALYAN, MEMBER.

 

Present:        Ms. Vandana Oberoi, Adv for the complainant.

                    Ms. Charu Sachdev, Adv for the OP.

                   

 

ORDER       SUBHASH GOYAL, PRESIDENT.

The case of the complainant, in brief, is that she was holder of Health Insurance Cover from 17.11.2010 till 16.11.2013 without any break and the total sum insured was Rs.4 Lacs. The opposite party has issued the policy after medical examination of the complainant. However, during the subsistence of the insurance policy in the month of April, 2013 the complainant went Fortis Hospital, Gurgaon where she was advised to go for some tests and on 18.05.2013 she was diagnosed for post menopausal bleeding and advised for hysteroscopy and polypectomy and thereafter the complainant remained admitted in the said hospital from 18.05.2013 to 19.05.2013 and during the stay the complainant had incurred a sum of Rs.70217/- on her treatment and the complainant submitted the claim along with all relevant documents for reimbursement but the claim was repudiated by the OP and the complainant had paid the said amount. However, the claim was repudiated on the ground of pre-existing disease and as such non reimbursement of the claim by the opposite party tantamounts to deficiency in service on the part of the opposite party. The complainant prayed that the opposite party be directed to pay Rs. 1 Lac with interest. She also sought compensation of Rs.50,000/- for harassment and mental agony. The complaint is supported with an affidavit and the documents placed on file.

2                 OP in its written reply has alleged that as per the available medical documents it was clearly evident that the complainant had Fibroid Uterus prior to the inception of the policy on 17.10.2010 which was not disclosed by the complainant in the Proposal Form and as such the complainant was guilty of suppressing and concealing the material facts from the opposite party at the time of issuance of policy violating foundational principle of insurance i.e. utmost good faith. The opposite party has rightly repudiated the claim of the complainant. The OP has produced the affidavit of Sameer Bhatnagar and documents Ex.DW-1/A to Ex.DW-1/R (colly).

3                 We have heard the learned counsel for the parties and have perused the record available on file.

4                 Therefore, from the facts and circumstances of the case, evidence on the file and the arguments advanced by the counsel for the parties, besides written arguments filed by OP it emerges that the complainant has filed the present complaint against the OPs alleging deficiency in service on their part on the ground that complainant was policy holder of the OP under Health Insurance Coverage from 17.11.2010 till 16.11.2013 without any break and the total sum insured was Rs.4 Lacs. However, during the subsistence of the insurance policy the complainant visited Fortis Hospital Gurgaon where she was diagnosed for post menopausal bleeding and advised for hysteroscopy and polypectomy and she remained admitted in the said hospital from 18.05.2013 to 19.05.2013 and incurred a sum of Rs.70,217/-. The complainant submitted the claim with the OP along with all relevant documents but it was rejected on the ground of pre-existing disease and as such non reimbursement of the claim tantamounts to deficiency in service.

5                 It was argued on behalf of the OP that complainant has suppressed the true and material facts regarding suffering of ailment prior to the inception of mediclaim policy and as such the claim has rightly been rejected. It was also argued that the complainant was suffering from Fibroids since 1993 as per the medical history and thus, the complainant herself has breached the principle of “Uberrima Fides” (utmost good faith)which was foundation of contractual obligation between the parties. It was also contended that initially the cash less policy was sanctioned but when the factum of suffering from Fibroids since 1993 was brought to the knowledge of the OP then the said facility was withdrawn and consequently, the claim was rejected on account of suppression of true facts as the complainant was having pre-existing disease prior to the inception of the policy. In support of her contention learned counsel for the OP has relied upon LIC Vs Asha (2001) 2 SCC 160,  Satwant Kaur Sandhu v New India Assurance Co. Ltd SC 2776 (2002), P.C.Chacko & Anr Vs Chairman, LIC Ltd AIR 2008 SC 424 and Life Insurance Corporation of India Vs Smt. G.M.Chanmaparsmma AIR 1991 SC 392.

6                 However, after going through the facts and circumstances of the case and the evidence placed on file it emerges that the complainant is having Health Insurance Policy of the OP since 2010 and she was admitted in the hospital in the month of April, 2013 on account of post menopausal bleeding and she was diagnosed as suffering from Fibroid. The law laid down in the above referred authorities is not in dispute. However, the applicability of the same depends upon the circumstances of each case. No doubt, as per terms and conditions of the insurance policy there was waiting period of 36 months to cover the pre existing disease. No doubt in the instant case the period of 36 months has not passed so far but the ground that she was suffering from Fibroid since 1993 and the same was pre-existing disease is not sustainable in the eye of law because as suffering from Fibroid is Asymptomatic and the same does not necessarily require medical treatment.

7                 As per the arguments of learned counsel for the complainant the cause of formation of polyps and fibroid may be pre menopause or post menopause. The cause is different and the place of origin is also different and the fibroid do not require treatment most of the time and is asymptomatic whereas the cause of formation of polyps is post menopause bleeding and always require treatment as mentioned in the Certificate given by Dr. Witty Raini, MD MRCOG (London) Consultant Obstetrician & Gynecologist (copy placed on file). Therefore, complainant was allegedly suffering from fibroid since 1993 and not from polyps and fibroids and polyps are two different problems. Therefore, the complainant who underwent surgery for polyps cannot be said to be suffering from pre-existing disease so as to fall within the Exclusion Clause. Therefore, non reimbursement of the claim tantamounts to deficiency in service on the part of the opposite party.

8                 Therefore, we allow the present complaint and direct the OP to reimburse the claim of the complainant to the tune of Rs.70217/- as per terms and conditions of the policy with interest @ 9 % p.a. from the date of filing of the present complaint till realization. The complainant is also entitled to compensation for harassment and mental agony as well as litigation expenses to the tune of Rs.20,000/-. The OP shall make the compliance of the order within 30 days from the date of receipt of the copy of this order. The parties be communicated of the order accordingly and the file be consigned to the records after due compliance.

 

Announced                                                   (Subhash Goyal)

03.05.2016                                                       President,

                                                                   District Consumer Disputes

                                                                   Redressal Forum, Gurgaon

 

(Jyoti Siwach)        (Surender Singh Balyan)

Member                 Member