Date of Filing: 02.10.2016
Date of Order: 06.08.2019
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM – I, HYDERABAD
P r e s e n t
HON’BLE Sri P.VIJENDER, B.Sc. L.L.B. PRESIDENT.
HON’BLE Smt. D.NIRMALA, B.Com., LLB., MEMBER
ON THIS THE TUESDAY THE 6th DAY OF AUGUST, 2019
C.C.No.492 / 2016
Between
Sri Challa Rajendra Babu S/o. Bhoomaiah,
Aged about 45 years, Occ: Private Employee
R/o.H.No. 9-1-193/1, Near Bhagavathi High School,
Bharatnagar, Karimnagar – 505 001,
Telangana State ……Complainant
And
M/s. Apollo Munich Health Insurance Co.Ltd.,
Regd. Office : Apollo Hospitals Complex,
Jubilee Hills, Hyderabad – 500 033,
Rep.by its Authorized Signatory. ….Opposite Party
Counsel for the complainants : Mrs. Ganga Bhavani
Counsel for the Opposite Party No.1 : Sri K.Visweswara Rao
O R D E R
(By Sri. Sri P. Vijender, B.Sc., LL.B., President on behalf of the bench)
1) This complaint has been preferred under Section 12 of Consumer Protection Act, 1986 alleging that repudiation of the claim by the opposite party amounts to deficiency of service. Hence a direction to the opposite party to reimburse the amount of Rs.1,21,230/- spent by the complainant for treatment in the hospital, to award a compensation of Rs.1,00,000/- for causing hardship , inconvenience and pain caused on account of repudiation of the claim, to award a further sum of Rs.50,000/- towards punitive damages and further sum of Rs.10,000/- towards cost of this complaint.
2) The complaint averments in brief are that :
The agent of the opposite party approached the complainant and explained advantages of health insurance policies floated by the opposite party. Having induced by the same the complainant obtained policy for a sum of Rs.1,00,000/- and paid the premium of Rs.1,985/- commenced from 28.2.2010 to 27.2.2011 and policy was delivered with a covering letter to the complainant and also they provided ID card. At the time of obtaining the policy the complainant informed to the agent of opposite party that he intends to undertake medical test. But the agent told that there is no need of it before purchase of the policy. The complainant was hale and healthy at the time of taking of the policy originally on 28.2.2010 and the policy was renewed from time to time. The policy was finally renewed on 28.2.2016. Opposite party provided cumulative bonus from time to time which was accumulated to Rs.60,000/- in view of regular renewal of the policy the total sum insured comes to Rs.1,60,000/-.
While matter’s stood thus in the month of May, 2016 there was swelling in right inguino scrotal. Hence the complainant visited Apollo hospital, Jubilee Hills and doctors diagnosed that he got right Inguino Scrotal Hernia . He was advised to undergo operation immediately. The complainant applied for pre-authorization for cashless treatment for undergoing surgery. But opposite party denied and intimated the same by letter dt.26.6.2016 and further stated admissibility of the claim would be decided , post review of the documents and policy conditions.
Since surgery was inevitable , the complainant got admitted in Apollo hospital, Jubilee Hills on 26.5.2016 and underwent for operation and was got discharged on 29.6.2016. For the surgery and other expenses he spent an amount of Rs.1,21,230/-. He submitted the claim with all required documents for reimbursement for the same. But opposite party sent a message to the mobile of the complainant on 7.6.2016 that his claim was rejected and an intimation to that effect has been sent to him.
The complainant did not suppress any material information regarding his health at the inception of the policy and though he renewed the policy 6 consecutive years did not submit any claim earlier for reimbursement of medical expenses.
There was no nexus to the cause for which the complainant was operated and suppression of information regarding pituitary Adenoma, which is alleged to have been undergone by the complainant about 13 years back. The development of right Inguinal Scrotal Hernia is common disease prevalent in most of the human beings. The repudiation of the claim amounts to unfair trade practice. Hence the present complaint.
3) The opposite party though appeared , did not file written version and did not lead any evidence either oral and documentary.
4) In the enquiry the complainant got filed his evidence affidavit reiterating the material facts of the complaint. He also got exhibited 6 documents in support of his claim. The opposite party filed written arguments.
5) On consideration of material brought on record the following points have emerged for consideration :-
1) Whether the opposite party justified to repudiate the claim?
2) Whether the complainant is entitled for the claims made in the
complaint?
- To what relief?
6) Point No.1: Complainant has placed the original policy obtained on 28.8.2010 and renewed policy letters on record along with the discharge summary issued from Apollo hospital in which he underwent surgery. Discharge summary in Exhibit A4 does not disclose that the complainant had any pre-existing ailment earlier to 2010. The original policy and renewal of policy letter proved that the complainant obtained the policy in the year 2010 and renewed it from time to time for 6 consecutive years and did not submit any claim earlier to the present one. Since policy was subsisting as on the date of incurring the expenditure by the complainant the opposite party / insurer is liable to reimburse the amounts spent by the complainant for treatment. The opposite party by not filing either written version or evidence affidavit failed to explain the reasons justifying repudiation of claim. There is no reason to disbelieve the complainant’s version. Since there is a denial from the opposite party about the complainants version and no reasons is forthcoming for the opposite party to reject the claim of the complainant the same is required to be accepted by this Forum. Accordingly the point is answered in favour of the complainant.
7) Point No.2:- Since the opposite parties failed to justify the repudiation of the claim it is liable to reimburse the amount spent by the complainant. Accordingly the point is answered.
8) PointNo.3:- In the result, the complaint is partly allowed directing the opposite party :
1, To pay an amount of Rs.1,21,230/- with interest thereon at 9% p.a.
from 26.5.2016 to the date of payment.
- The opposite party caused mental agony and hardship to the complainant
by repudiating the claim. Hence liable to pay a sum of Rs.25,000/- as compensation.
3. To pay Rs.5,000/- towards costs of this complaint.
Time for compliance is thirty days from service of this order.
Dictated to steno transcribed and typed by her and pronounced by us on this the 6th day of August, 2019.
MEMBER PRESIDENT
APPENDIX OF EVIDENCE
WITNESS EXAMINED
NIL
Exhibits filed on behalf of the Complainant:
Ex.A1 – Renewal of Easy Health Insurance policy.
Ex.A2 - Schedule – Easy Health Individual standard
Ex.A3 – Repudiation letter
Ex.A4 - Discharge summary
Ex.A5 – In patient bill
Ex.A6 - Check list of enclosures for submission of claims.
Exhibits filed on behalf of the Opposite parties:
Nil
MEMBER PRESIDENT
