Chandigarh

StateCommission

A/318/2018

Apollo Munich Health Insurance Company Ltd. - Complainant(s)

Versus

Rajeev Garg - Opp.Party(s)

Sachin Ohri, Adv.

18 Jan 2019

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

 

 

Appeal No.	:	318 of 2018
Date of Institution	:	23.10.2018
Date of Decision	:	18.01.2019

 

Apollo Munich Health Insurance Co. Limited, Branch Office 4^th Floor, SCO 50-51, Sector 34-A, Chandigarh and Head Office 10^th Floor, Tower-B, Building No.10, DLF Cyber City, DLF City, Phase-II, Gurgaon (Haryana) through Deepti Rustagi, Vice President – Legal & Compliance, Authorized Signatory.

 …….Appellant.

 

Versus

 

Sh. Rajeev Garg S/o Sh. Roshan Lal R/o H.No.346, Phase-2, Mohali.

 

...Respondent.

 

Appeal under Section 15 of the Consumer Protection   Act, 1986 against  order dated 21.08.2018 passed by District   Consumer Disputes Redressal Forum-I, U.T. Chandigarh  in Consumer Complaint No.631 of 2016.

 

BEFORE: MRS. PADMA PANDEY, PRESIDING MEMBER.

                MR. RAJESH K. ARYA, MEMBER.

 

Argued by:

 

Sh. Sachin Ohri, Advocate for the appellant.

 

PER  RAJESH  K.  ARYA, MEMBER

                   The appellant/opposite party has filed this appeal against order dated 21.08.2018 passed by District Consumer Disputes Redressal Forum-I, U.T., Chandigarh (in short ‘the Forum’ only), vide which, complaint bearing No.631 of 2016 filed by the respondent/complainant was partly allowed in the following manner:-

“9.        In view of the foregoings, we are of the opinion that the present Complaint must succeed. The same is accordingly partly allowed. Opposite Parties are, jointly and severally, directed as under:-

[a]    To pay the claim amount of Rs.1,21,673/- to the Complainant along with interest 9% per annum from the date of repudiation of the claim (Annexure C-7) i.e. 12.04.2016, till realization.

[b]    To pay Rs.25,000/- as compensation on account of deficiency in service and causing mental and physical harassment to the Complainant; 

[c]    To pay Rs.10,000/- as cost of litigation;

10.     The above said order shall be complied within 30 days of its receipt by the Opposite Parties; thereafter, they shall be liable for an interest @12% per annum on the amount mentioned in sub-para [a] above from the date of repudiation of the claim i.e. 12.04.2016, till it is paid. The compensation amount as per sub-para [b] above, shall carry interest @12% per annum from the date of institution of this complaint, till it is paid, apart from cost of litigation as in sub-para [c].”

2.              Before the Forum, it was case of the complainant that lured by the lucrative benefits projected by the Agent of the Opposite Parties, the complainant purchased Easy Health Individual Standard Policy, which was valid for the period 23.02.2010 to 22.02.2011. It was further stated that the complainant got the said Policy renewed for the period 2011-12, 2012-13, 2013-14, 2014-15 and 2015-16. It was further stated that in January 2016, the complainant fell ill and was taken to Garg Diabetes and Heart Care Centre, Mohali in an emergency condition, where he remained admitted from 11.01.2016 to 17.01.2016. It was further stated that the complainant spent an amount of Rs.1,21,673/- on his treatment. It was further stated that after discharge from the hospital, the complainant submitted all the documents required for releasing the claim along with the original medical bills, however, vide letter dated 12.04.2016, the Opposite Parties repudiated the claim of the complainant. Hence, complaint was filed before the Forum.

3.             The opposite parties, in their reply, while admitting the factual matrix of the case, stated that the Hospital where the complainant was admitted does not fulfill the criteria of the Hospital as per the definition mentioned in the Policy and, therefore, the claim was rightly repudiated under Section VIII definition 22 of the Policy. It was further stated that neither there was any deficiency, in rendering service, on the part of the opposite parties nor they indulged into any unfair trade practice. The remaining averments, were denied, being wrong.

4.            The parties led evidence. The Forum, on analysis of pleadings of the parties, documents on record, and the arguments addressed, partly allowed the complaint as referred to above.

5.             The appellant has assailed the impugned order passed by the Forum on the ground that that the Forum did not appreciate the terms and conditions of the Policy specifically Clause 22 of the Policy, as per which, claim was not payable because the treatment was taken on OPD basis, which was not covered under the Policy opted by the insured. By raising the aforesaid argument, it was prayed that appeal be allowed and the impugned order passed by the Forum be set aside.

6.             After going through the evidence on record and submissions of the Counsel for the appellant, we are of the opinion that the appeal is liable to be dismissed, at the preliminary stage, for the reasons to be recorded hereinafter. In our considered opinion, the aforesaid argument raised by the Counsel for the appellant does not hold ground. The Forum in Para 8 of its order has rightly observed that no doubt, the opposite parties have issued list of 160 Hospital in the said Policy, under which, medical reimbursement/treatment was not allowed but they did not provide any list of the empanelled hospitals in the said Policy. The Forum further rightly held that there was no condition in the Policy that the complainant could not get treatment from the non-network hospital. Discharge Summary (Annexure C-3) reveals that the respondent/complainant remained admitted in Garg Diabetes & Heart Care Centre from 11.01.2016 to 17.01.2016 and being an indoor patient, he was entitled to reimbursement of medical claim of Rs.1,21,673/-, which he spent on his treatment. It is not a case of pre-existing disease, where any material information was not disclosed. It is a clear cut case where the respondent/complainant was diagnosed to have Diabetes Mellitus with dehydration and sepsis, for which, he took treatment from the aforesaid Hospital by spending aforesaid amount of Rs.1,21,673/-. We, therefore, affirm the view held by the Forum that the opposite parties illegally rejected the claim of the complainant on false and flimsy grounds and as such, they are liable to pay the claim amount to the complainant. The Forum rightly directed the opposite parties to pay the claim amount of Rs.1,21,673/- to the complainant alongwith interest @9% p.a. from the date of repudiation of the claim i.e. 12.04.2016 till realization. It also rightly awarded an amount of Rs.25,000/- and Rs.10,000/- towards compensation on account of deficiency in service and causing mental and physical harassment to the complainant and cost of litigation.

7.             Hence, we are of the opinion that the order passed by the Forum, being based on the correct appreciation of evidence and law, on the point, does not suffer from any illegality or perversity.

8.             No other point was raised by the Counsel for the appellant.

9.             For the reasons recorded above, this appeal being devoid of any merit, is dismissed in limine, with no order as to costs. The impugned order passed by the District Forum is upheld. Consequently, in view of dismissal of appeal, the application for condonation of delay in filing the instant appeal stands dismissed having been rendered infructuous.

10.           Certified copies of the order be sent to the parties free of charge.

11.           File be consigned to the Record Room after completion.

Pronounced

18.01.2019.

 (PADMA PANDEY)

PRESIDING MEMBER

 

 

 

(RAJESH K. ARYA)

MEMBER

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