Tamil Nadu

South Chennai

CC/360/2014

Dr.P.Rajaji - Complainant(s)

Versus

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

M/s.K. Ramani

18 Sep 2019

ORDER

                                                                  Complaint presented on : 19.08.2014

                                                                    Date of Disposal            : 18.09.2019

                                                                                  

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (SOUTH)

@ 2^ND Floor, T.N.P.S.C. Road, V.O.C. Nagar, Park Town, Chennai – 3.

 

PRESENT: THIRU. M. MONY, B.Sc., L.L.B, M.L.                    : PRESIDENT

TR. R. BASKARKUMARAVEL, B.Sc., L.L.M., BPT., PGDCLP.  : MEMBER

 

C.C. No.360/2014

DATED THIS WEDNESDAY THE 18^TH DAY OF SEPTEMBER 2019

                                 

Dr. P. Rajaji,

S/o. Mr. K. Panchapagesan,

New No.92, Old No.50, Soorappa Mudali Street,

Triplicane,

Chennai – 600 005.                                                        .. Complainant.                                                       ..Versus..

1. M/s. Apollo Munich Health Insurance Company Ltd.,

Represented by its Branch head,

Flat No.2-B, 2^nd Floor,

“Dev Regency”,

No.6, I Main Road,

Gandhi Nagar,

Adayar,

Chennai – 600 020.

 

2. M/s. Apollo Munich Health Insurance Company Ltd.,

Rep. by its Authorised Signatory,

Aditya JR Towers,

Third Floor, 8-2-120/86/9 A & B,

Road No.2, Banjara Hills,

Hyderabad,

Andra Pradesh – 500 033.                                     ..  Opposite parties.

 

Counsel for the complainant     : M/s. K. Ramani & others

Counsel for the Opposite party : Mrs. Elveera Ravindran & another

 

ORDER

THIRU. M. MONY, PRESIDENT

       This complaint has been filed by the complainant against the opposite party under section 12 of the Consumer Protection Act, 1986 prays to reimburse a sum of Rs.86,632/- being expenses incurred while undergoing treatment at Rigid Hospital Pvt. Ltd. and to pay sum of Rs.5,00,000/- towards compensation for mental agony, stress and loss of professional income to the complainant.

1.    The averments of the complaint in brief are as follows:-

The complainant submits that he is a practicing Advocate and former Secretary of Tamil Nadu Bar Council maintaining good reputation and holding practice.   The complainant submits that during September 2012, the 1^st opposite party’s officials approached the complainant and canvassed for Insurance policy; believing the sweet words, the complainant become the member of the scheme and availed health policy.   The 1^st opposite party officials did not inform the terms and conditions of the insurance policy in full before collecting the premium amount.  The complainant was subjected to medical test by the opposite parties before issuing insurance cover note.     The complainant submits that the first period of coverage of the Health Insurance Policy expired on 27.09.2013.   The Marketing Executive of the 1^st opposite party approached the complainant and insisted for renewal stating that the complainant entitled no claim bonus and other benefits.   Thereby, the total insurance cover enhanced Rs.1,00,000/- the following year if the insurance coverage and it would be Rs.2,28,000/- and the Marketing Executive renewed the policy for further period.  

2.     The complainant submits that during the year December 2013, the complainant had a sudden severe pain.  He was diagnoized of stone formation in the gall bladder by Dr. J.S. Raj Kumar attached to Life Line Ridgid Hospital Pvt. Ltd. and was advised to undergo a surgery.   Immediately the complainant informed the hospital authorities about the existence of the health insurance policy issued by the 1^st opposite party and the complainant informed the opposite party insurance company also the hospital authorities informed the complainant that there is no cover assured by the insurance policy.   Hence, the complainant undergone surgery on 28.12.2013 and paid a sum of Rs.2,225/- towards investigation, Rs.83,907/- towards cost of medicine, Rs.500/- towards professional fees and hospital charges out of his own funds.  Thereafter, the complainant submitted a claim with the opposite parties attaching all the original bills and the receipts on 17.01.2014.   The opposite parties by letter dated:10.02.2014 repudiated the claim stating that the claim was within the period of 2 years from the date of issuance of Health Insurance Policy. The complainant submits that the repudiation of the medi-claim by the opposite party is illegal and not justifiable and is against the terms and conditions of the policy.  The complainant had a sudden pain and was admitted in the above said hospital.   The complainant health position is very normal when availing the policy.   The complainant had no health problem till he had the sudden pain and diagnosed for formation of stone in the gall bladder.  The exclusion clause mentioned in Section 6 and Clause (c) specific waiting periods of the terms and conditions of the policy mentioned about calculus diseases of Gall Bladder which is a wide term.   A calculus is a stone that forms in an organ or duct of the body.  Formation of calculi is known as Cholelithiasis.  The complainant will not fall under the said exclusion clause and the opposite parties had repudiated the claim only for the sake of rejecting it.   The act of the opposite parties 1 & 2 amounts to deficiency in service and unfair trade practice which caused great mental agony.    Hence, the complaint is filed.

3.      The brief averments in the written version filed by opposite parties 1 & 2 is as follows:

The opposite parties 1 & 2 specifically deny each and every allegations made in the complaint and put the complainant to strict proof of the same.   The opposite parties 1 & 2 state that as per the standard practice of the opposite parties every proposer applies for the policy by means of an application is required to fulfil the material information in the said Proposal Form. The opposite parties state that considering the declaration, information and the medical history policy No.140600/11001/1000328630 was issued for the period 28.09.2012 to 27.09.2013.  The policy was renewed on the written request of the complainant for the period from 28.09.2013 to 27.09.2014 and was again renewed for the period from 28.09.2014 to 27.09.2016.  The opposite parties state that the policy kit contains all relevant documents were duly delivered to the complainant at various times regarding benefits, terms and conditions etc.  The opposite parties received pre-authorisation form for cashless facility on 11.12.2013 from Rigid Hospital Pvt. Ltd., Chennai for the treatment of the complainant’s abdominal pain, diagnosed as Cholelithiasis with date of admission as 12.12.2013 with estimated cost of Rs.75,000/-.

 4.    Further the opposite parties state that after reviewing the Pre-authorisation for the cashless treatment; the claim was rejected stating that, “Cashless facility is denied, since treatment of presenting ailments is within 2 years exclusion” under the members Easy Health Individual Standard Policy.   The opposite parties 1 & 2 state that on 25.01.2014, the same claim was made for reimbursement of Rs.86,632/- towards the medical expenses along with bill and admission discharge summary was rejected.   As per the Discharge summary the diagnosis is Cholelithiasis and surgery done was for Laparoscopic Cholecystectomy.   The copy of claim form along with other documents as submitted by the complainant was  rejected stating that the policy and the commencement of the policy date is 28.09.2012.  Hence, we regret to inform you that your claim is repudiated under Sec.VI A (ii) of the policy”.   There is no deficiency in service on the part of the opposite parties and hence, the complaint is liable to be dismissed.

5.     To prove the averments in the complaint, the complainant has filed proof affidavit as his evidence and documents Ex.A1 to Ex.A5 are marked.  Proof affidavit of the opposite parties 1 & 2 is filed and documents Ex.B1 to Ex.B8 are marked on the side of the opposite parties 1 & 2.

6.      The points for consideration is:-

1. Whether the complainant is entitled to reimburse a sum of Rs.86,632/- expended towards medical treatment as prayed for?

2. Whether the complainant entitled to a sum of Rs.5,00,000/- towards compensation for mental agony, deficiency in service, professional loss etc with cost as prayed for?

7.      On point:-

Both parties filed their respective written arguments.  Heard their Counsels also.  Perused the records namely; the complaint, written version, proof affidavits, documents, written arguments etc.  The complainant pleaded and contended that he is a practicing Advocate and former Secretary of Tamil Nadu Bar Council maintaining good reputation and holding practice.   Further the complainant contended that during September 2012, the 1^st opposite party’s officials approached the complainant and canvassed for Insurance policy; believing the sweet words of the opposite party, the complainant become the member of the scheme and availed health policy.   The 1^st opposite party officials did not inform the terms and conditions of the insurance policy in full before collecting the premium amount; But the complainant was subjected to medical test by the opposite parties before issuing insurance cover note.  Ex.A1 & Ex.A2 shows the policy conditions and easy health insurance policy kit showing the details of payment of premium.  Further the contention of the complainant is that the first period of coverage of the Health Insurance Policy expired on 27.09.2013.  The Marketing Executive of the 1^st opposite party approached the complainant and insisted for renewal stating that the complainant entitled no claim bonus and other benefits.  Thereby, the total insurance cover enhanced to Rs.1,00,000/- the following year if the insurance coverage and it would be Rs.2,28,000/- and the Marketing Executive renewed the policy for further period.

8.     Further the complainant contended that during the year December 2013, the complainant had a sudden severe pain.  He was diagnoized of stone formation in the gall bladder by Dr. J.S. Raj Kumar attached to Life Line Ridgid Hospital Pvt. Ltd. and was advised to undergo a surgery.   Immediately the complainant informed the hospital authorities about the existence of the health insurance policy issued by the 1^st opposite party and the complainant informed the opposite party insurance company also the hospital authorities informed the complainant that there is no cover assured by the insurance policy.   Hence, the complainant undergone surgery on 28.12.2013 and paid a sum of Rs.2,225/- towards investigation, Rs.83,907/- towards cost of medicine, Rs.500/- towards professional fees and hospital charges out of his own funds.  Ex.A3 consists of the details of medical bills.   Thereafter, the complainant submitted a claim form with the opposite parties attaching all the original bills and the receipts on 17.01.2014 as per Ex.A4.   The opposite parties by letter dated:10.02.2014 repudiated the claim as per Ex.A5 stating that the claim was within the period of 2 years from the date of issuance of HIP. ( Health Insurance Policy).

9.     The learned Counsel for the complainant would contend that the repudiation of the medi-claim by the opposite party is illegal and not justifiable and is against the terms and conditions of the policy.  The complainant had a sudden pain and was admitted in the impugned hospital for treatment.  The complainant’s health position is very normal when availing the policy.   The complainant had no health problem till he had the sudden pain and diagnosed for formation of stone in the gall bladder.   As per the terms and condition of the policy Ex.A1 in the Specific Waiting Periods which reads as follows:

Specific Waiting Periods

Sec. 6 Clause c) The illnesses and treatments listed below will be covered subject to a waiting period of 2 years as long as in the third Policy Year the Insured Person has been insured under an Easy Health Policy continuously and without any break:

i. Illnesses: arthritis if non infective; calculus diseases of gall bladder  and urongenital system; cataract; fissure/fistula in anus, haemorrhoids, pilonidal sinus, gastric and duodenal ulcers; gout and rheumatism; internal tumors, cysts, nodules, polyps including breast lumps (each of any kind unless malignant); osteoarthritis and osteoprorosis if age relaged; polycystic ovarian diseases; sinusitis and related disorders and skin tumors unless malignant.

ii.  Treatments: benign ear, nose and throat (ENT) disorders and surgeries (including but no limited to adenoidectomy, mastoidectomy, tonsillectomy and tympanoplasty);dilatation and curettage (D & C); hysterectomy for menorrhagia or fibromyoma or prolapsed of uterus unless necessitated by malignancy; joint replacement; myomectomy for fibroids; surgery of gallbladder and bile duct unless necessitated of malignancy; surgery of benign prostatic hypertrophy; surgery of hernia; surgery of hydrocele; surgery for prolapsed inter vertebral disk; surgery of varicose veins and varicose ulcers; surgery on tonsils and sinuses; surgery for nasal septum deviation.

iii. However, a waiting period of 2 years will not apply if the Insured Person was insured continuously and without interruption for at least 2 years under any other Indian insurer’s individual health insurance policy for the reimbursement of medical costs for inpatient treatment in a hospital”

proves that the treatment related to gall bladder is exempted.  Hence, the repudiation of claim by the opposite party squarely come under unfair trade practice and which amounts to deficiency in service. The complainant is claiming a sum of Rs.86,632/- towards the medical expenses and a compensation of Rs.5,00,000/- towards mental agony, deficiency in service, professional loss etc.

11.    The learned Counsel for the opposite parties 1 & 2 contended that as per the standard practice of the opposite parties every proposer applies for the policy by means of an application is required to fulfil the material information given in Ex.B1.  In this case, the opposite parties received the duly filled and signed proposal form Ex.B1 from the complainant on 14.08.2012.  As per para No.9 of the proposal form it reads as follows:

9. DECLARATION & WARRANTY ON BEHALF OF ALL PERSONS PROPOSED TO BE INSURED

• I hereby declare and warrant on my behalf and on behalf of all persons proposed to be insured that the above statements are true and complete in all respects.   I agree that this proposal and the declarations shall be the basis of the contract between me and all person to be insured and Apollo Munich Health Insurance Company Ltd.
• I further consent and authorize Apollo Munich Health Insurance Company Ltd. and/or any of their authorized representatives to seek medical information from any hospital/consultant/insurer that I or any person proposed to be insured has attended or may attend in future concerning any disease or illness or injury in respect to a particular claim.
• I agree to Apollo Munich Health Insurance Company Limited taking appropriate measures to capture the voice log for all such telephonic transactions carried out by me, in accordance with procedures/regulations.
• I authorize Apollo Munich Health Insurance and associate partners to contact me via e-mail, phone or SMS.

12.    Further the contention of the opposite parties 1 & 2 is that considering the declaration, information and the medical history policy No.140600/11001/1000328630 was issued for the period from 28.09.2012 to 27.09.2013 Ex.B2 & Ex.B3 are policies.   The policy was renewed on the written request of the complainant for the period from 28.09.2013 to 27.09.2014 and was again renewed for the period from 28.09.2014 to 27.09.2016.   As per Ex.B4, it is proved that the complainant is continuing the policy without any break and the policy is subsisting.  Further the contention of the opposite parties 1 & 2 is that the policy kit contains all relevant documents were duly delivered to the complainant at various times regarding benefits, terms and conditions etc.   The opposite parties received pre-authorisation form for cashless facility on 11.12.2013 from Rigid Hospital Pvt. Ltd., Chennai for the treatment of the complainant’s abdominal pain, diagnosed as Cholelithiasis as per Ex.B5.   But on a careful perusal of Ex.B5 showing the scan report that

“MR-CHOLANGIO PANCREATICOGRAPHY

Multiple tiny calculi of about 4 to 5 mm seen in the neck of the gall bladder”

proves that the allegation of cholilithiasis is false. 

13.    Further the contention of the opposite parties 1 & 2 is that after reviewing the Pre-authorisation form, the cashless and the claim was rejected, “since treatment of presenting ailments is within 2 years exclusion” as per Ex.B6.   But on a careful perusal of Ex.A1, it is very clear that surgery related to gall bladder and bile duct is exempted from the waiting period of 2 years.  Further the contention of the opposite parties 1 & 2 is that on 25.01.2014, the same claim was made for reimbursement of Rs.86,632/- towards the medical expenses along with bill and admission, discharge summary as per Ex.B7 was duly rejected as per Ex.B8 stating that u/s VI(A)(I) of the policy the claim is not maintainable.  But on a careful perusal of S.VI(A)(II) the treatment, surgery etc to the gall bladder, there is no iota of the disease related to gall bladder mentioned.   S. VI (A)(I) is related to UROGENITAL diseases.  But in this case, it is very clear that the stone in the gall bladder is removed by surgery and the repudiation of claim by the opposite parties proves the deficiency in service and unfair trade practice played by the opposite parties.

In the result, this complaint is allowed in part.  The opposite parties 1 & 2 are jointly and severally liable to pay a sum of Rs.86,632/- (Rupees Eighty six thousand six hundred and thirty two only) being medical expenses incurred by the complainant along with interest at the rate of 9% p.a. from the date of presentation of this complaint (i.e.) 19.08.2014 to till the date of this order (i.e.) 03.09.2019 and to pay a sum of Rs.45,000/- (Rupees Forty five thousand only) towards compensation for mental agony with cost of Rs.5,000/- (Rupees Five thousand only) to the complainant.

The aboveamounts shall be payablewithin six weeks from the date of receipt of the copy of this order, failing which, the said amounts shall carry interest at the rate of 9% p.a. to till the date of payment.

Dictated  by the President to the Steno-typist, taken down, transcribed and computerized by her, corrected by the President and pronounced by us in the open Forum on this the 18^th day of September 2019. 

 

MEMBER                                                                                PRESIDENT

 

COMPLAINANT SIDE DOCUMENTS:-

Ex.A1		Copy of Policy conditions issued by the opposite parties
Ex.A2	29.09.2012	Copy of letter issued by the opposite parties enclosing the Easy Health Insurance Policy Kit and showing the details of premium paid
Ex.A3	30.12.2013	Copy of the medical bill
Ex.A4	17.01.2014	Copy of the claim form
Ex.A5	10.02.2014	Copy of repudiation letter from the opposite parties

 

OPPOSITE PARTIES SIDE DOCUMENTS:-  

Ex.B1		Copy of Proposal Form signed by the complainant
Ex.B2		Copy of the Policy Schedule
Ex.B3		Copy of policy wordings & claim procedure
Ex.B4		Copy of Schedule – Easy Health Individual Standard
Ex.B5		Copy of pre-authorisation form along with documents
Ex.B6	11.12.2013	Copy of letter dated:11.12.2013 sent by the opposite parties to complainant denying cashless service and the reason therefore
Ex.B7		Copy of claim form, Discharge Summary and other documents
Ex.B8	08.02.2014	Copy of repudiation letter dated:08.12.2014

 

 

 

MEMBER                                                                                PRESIDENT