BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

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Saibal Sarkar S/o N.N.Sarkar, r/o H.No.679, Phase I, SAS Nagar, Mohali.

…..Complainant

                                      V E R S U S

1.       M/s Apollo Munich Health Insurance Company Limited, 10^th Floor, Tower B, Building No.10, DLF Cyber City, DLF City, Phase II, Gurgaon, Haryana – 122002, through its Managing Director.

2.       M/s Apollo Munich Health Insurance Company Limited, SCO No.50-51, 4^th Floor, Sector 34-A, Chandigarh through its authorized signatory.

                                                ……Opposite Parties

CORAM:     SH.P.D.GOEL                                              PRESIDENT

                   SH.RAJINDER SINGH GILL                         MEMBER

                   DR.(MRS) MADANJIT KAUR SAHOTA              MEMBER

Argued by:    Sh.Rajesh Verma, Counsel for the complainant.

                        Sh.Nitin Thatai, Counsel for the OPs.

PER P.D.GOEL,PRESIDENT

1.           Briefly stated, the facts of the case are that the complainant took Easy Health Floater Insurance Policy bearing No. 110300/11051/100002000-02, valid from 29.1.2011 to 28.1.2012, for a sum of Rs.4 lacs. It is the case of the complainant that on 2.2.2011, he was admitted in Omni Hospital, SCO No.343-45, Sector 34-A, Chandigarh with the problem of Urospsis & Epididymyoorchitis and was discharged on 5.2.2011. He spent a sum of Rs.15,588/- on treatment.

              It is further averred that the OPs had undertaken to provide cashless hospitalization, so he requested the doctors of Omni Hospital for cashless hospitalization and the said request was forwarded to Family Health Plan (TPA Ltd.) which is third party Administrator. The TPA vide its letter dated 4.2.2011 showed its inability to provide cashless hospitalization on the basis of the terms and conditions of the policy.

              It is the case of the complainant that he had not received any terms and conditions along with the schedule. It is further the case of the complainant that the OPs vide letter dated 16.3.2011 repudiated the claim of the complainant on the ground that the treatment of the symptoms had started before the start of the policy and as per the terms and conditions of the policy any pre-existing disease will not be covered until 36 months of continuous coverage. It has been further stated that the complainant was not suffering from any pre-existing disease. The complainant sent a letter dated 31.3.2011 to OP No.2 with a request to settle the claim but to no avail. Hence, this complaint.

2.           OPs No.1 & 2 filed the joint reply, wherein, it has been pleaded that at the time of admission, the complainant was examined by Dr.Ramandeep Singh of Omni Hospital. He was diagnosed as a follow up case of stricture urethra (treated 18 years ago). It has been admitted that the third party administrator showed its inability to issue authorization for cashless hospitalization due to the fact that pre-existing disease could not have been ruled out. It has been further replied that the complete insurance policy including all the terms and conditions of the policy documents were duly supplied to the complainant. It is further replied that the claim was rightly repudiated. Denying all the material allegations of the complainant and pleading that there has been no deficiency in service on their part and prayer for dismissal of the complaint with costs has been made.  

3.           Parties led evidence in support of their contentions.

4.           We have heard the learned Counsel for the parties and have also perused the record. 

5.           The learned Counsel for the complainant argued that the complainant took Easy Health Floater Insurance Policy, valid from 29.1.2011 to 28.1.2012 – Annexure C-1, for a sum of Rs.4 lacs. That on 2.2.2011, the complainant got admitted in Omni Hospital, Sector 34-A, Chandigarh with the problem of Urospsis & Epididymyoorchitis and he spent Rs.15,588/- on treatment. The said policy was cashless hospitalization. The request of the complainant was forwarded to Family Health Plan (TPA) Ltd. – 3^rd party Administrator, who vide letter dated 4.2.2011 – Annexure C-7 showed its inability to provide cashless hospitalization. It was lastly argued that the OPs repudiated the claim vide repudiation letter dated 16.3.2011 - Annexure C-8 on the ground that the disease/symptoms has started before the start of the policy and any pre-existing disease will not be covered until 36 months of continuous coverage.

6.           The learned Counsel for OPs No.1 & 2 submitted that the complainant was examined by Dr.Ramandeep Singh of Omni Hospital. He was diagnosed as a follow up case of stricture urethra and was treated for the same 18 years ago. It was lastly argued that the complainant was suffering from pre-existing disease, so the claim has been rightly repudiated.

7.           The other facts are admitted. The only point which calls decision from this Forum is whether the complainant was suffering from any pre-existing disease, which he has concealed and has not disclosed at the time of taking the policy. The answer to this is in the negative.

8.           Admittedly as per the terms and conditions placed on record by the OPs, the pre-existing disease will not be covered until 36 months of continuous coverage have elapsed. Exhibit R-4 at page No.31 of the reply is Cashless Authorization Requisition Form, wherein, the treating doctor has recorded that the patient had a pain in the left testicle, fever since 1 day, K/C/O Stricture Urethra and Torsion R/o By Investigations and in the column of ‘Diabeties’, it has been recorded “detected on admission”. Admittedly, the said observation made by the treating doctor had not been supported by his affidavit, therefore, it looses its evidentiary value. The OPs in the reply had specifically stated that the complainant was examined by Dr.Ramandeep Singh of Omni Hospital, Chandigarh and was diagnosed as a follow up case of stricture urethra. The OPs have neither produced Dr.Ramandeep Singh as a witness nor has produced his affidavit to prove the said assertion/fact. At page No.37 of the reply, Dr.Ramandeep Singh had recorded that the complainant is K/C/O Neurogenic Bladder and at page No.38, it is further recorded that the complainant is a follow up case of stricture urethra treated 18 years ago. Was doing well with occasional clean intermittent catheterization. The said observation of Dr.Ramandeep Singh is also not supported by his affidavit. More so, he has categorically recorded that the complainant was treated for stricture urethra since 18 years ago and was doing well with occasional clean intermittent catheterization. Since, the complainant was treated for the said disease 18 years ago and is doing well with occasional clean intermittent catheterization, so we have got no hesitation to conclude that the occasional clean intermittent catheterization will not fall under the definition of pre-existing disease.

9.           The OPs have not produced any other evidence on record to prove the pre-existing disease except the evidence, which has been discussed in para supra(s). Thus, we are of the opinion that the OPs have failed to prove that the complainant was suffering from pre-existing disease, consequently, the repudiation of the claim is held to be illegal.

10.         The complainant has filed this complaint with the prayer that the OPs be directed to pay     Rs.15,588/-. The complainant has placed on record the bill of Rs.10,355/- - Annexure C-4 along with receipt dated 5.2.2011 bearing No.61501 - Annexure C-5. The complainant has also produced on record the cash memo – Annexure C-6 of Santosh Medi Hub, Sector 34-A, Chandigarh to prove the payment of Rs.5233/-.

11.         Now it is proved on record that the complainant had spent Rs.15,588/- on his treatment.

12.         As a result of the above discussion, the complaint is allowed and OPs are directed to pay a sum of Rs.15,588/- to the complainant along with interest @ 12% p.a. from the date of filing of the complaint till its realization. The OPs are also directed to pay Rs.5,000/- to the complainant as costs of litigation. This order be complied with by the OPs within one month from the date of receipt of certified copy of the order.

13.         The certified copies of this order be sent to the parties free of charge. The file be consigned.