Haryana

StateCommission

A/1302/2016

APOLLO MUNICH HEALTH INSURANCE CO. - Complainant(s)

Versus

RENU RASTOGI - Opp.Party(s)

SANDEEP SURI

12 Sep 2017

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal No  :      1302 of 2016

Date of Institution:        30.12.2016

Date of Decision :         12.09.2017

 

Apollo Munich Health Insurance Company Limited 10^th Floor, ‘Tower-B’ DLF Cyber City, DLF City, Phase-II, Gurgaon, Haryana, through its Director/Managing Director.

                                      Appellant-Opposite Party

Versus

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

                                      Respondent-Complainant

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Mr. Balbir Singh, Judicial Member.

                                                                                                         

Argued by:          Shri Sandeep Suri, Advocate for appellant.

                             Ms. Saumya Ahluwalia, Advocate for respondent.

 

                                                   O R D E R

 

NAWAB SINGH J.(ORAL)

 

                    Apollo Munich Health Insurance Company Limited (for short ‘the Insurance Company’)-Opposite Party, is in appeal against the order dated May 03^rd, 2016 passed by District Consumer Disputes Redressal Forum, Gurgaon (for short ‘the District Forum’) whereby it directed the Insurance Company to pay Rs.70,217/-, the expenses incurred on her treatment by Renu Rastogi-complainant (respondent herein), along with interest at the rate of 9% per annum from the date of filing of the complaint till its realization and Rs.20,000/- compensation for harassment, mental agony and litigation expenses.

2.                The complainant purchased Easy Health Individual Standard Insurance Policy (Exhibit DW1/C) from the Opposite Party-Insurance Company for the period November 17^th, 2010 to November 16^th, 2011. The sum insured was Rs.4.00 lacs. After purchase of the policy, the same was got renewed continuously and without any break from time to time.

3.                On May 18^th, 2013 the complainant was admitted in Fortis Memorial Research Institute, Gurgaon and spent an amount of Rs.70,217/- on her treatment. She filed claim with the Insurance Company but the same was repudiated vide letter dated July 10^th, 2013 on the ground that the insured was a known case of Fibroid Uterus since 1993 and as such the insurance company was not liable to pay the amount in view of Section 6 (d) of “Exclusions” of the insurance policy. Relevant part of Section 6 “Exclusions” reads as under:-

                   “Section 6. Exclusions

(d)     Pre-existing Conditions will not be covered until 36 months of continuous coverage have elapsed, since inception of the first Easy Health policy with us, but

1)      If the Insured Person is presently covered and has been continuously covered without any break under:

a)      an individual health insurance plan with an Indian insurer for the reimbursement of medical costs for inpatient treatment in a Hospital,

          OR

b)      any other similar health insurance plan from us, then Section 6 d of the Policy stands deleted and shall be replaced entirely with the following:

i)        The waiting period for all Pre-existing Conditions shall be reduced by the number of continuous preceding years of coverage of the Insured Person under the previous health insurance policy; AND

ii)       establishes to our satisfaction that he was unaware of and had not taken any advice or medication for such illness or treatment.

iii)      if the proposed Sum Insured for a proposed Insured Person is more than the Sum Insured applicable under the previous health insurance policy (other than as a result of the application of Benefit 5a), then the reduced waiting period shall only apply to the extent of the Sum Insured under the previous health insurance policy.”

4.                The complainant filed complaint under Section 12 of the Consumer Protection Act, 1986 before the District Forum.

5.                The Insurance Company contested the complaint by filing written version while reiterating the fact stated in the repudiation letter dated July 10^th, 2013.

6.                After evaluating the pleadings of the parties and the evidence adduced on the record, the District Forum allowed complaint directing the opposite party as detailed in paragraph No.1 of this order.

7.                The appellant has filed an application under Section 5 of the Limitation Act seeking condonation of 72 days delay in filing the appeal, though as per report of the registry, the delay is of 181 days. The ground taken in the application is that due to lengthy process for taking approval for filing of the appeal, delay occurred in filing of the appeal. 

8.                Learned counsel for the appellant has contended that the delay caused in filing of the appeal is unintentional and it has occurred due to circumstances beyond the control of the appellant.

9.                A 30 days period has been prescribed in Section 15 of the Consumer Protection Act, 1986 (for short ‘Act’), for filing appeal against the order of the District Forum. However, the proviso contained therein permits the State Commission to entertain an appeal after the expiry of the period of 30 days if it is satisfied that there is ‘sufficient cause’ for not filing the appeal within the period prescribed. The expression ‘sufficient cause’ has not been defined in the Act, rightly so, because it would vary per facts and circumstances of each particular case.

10.              It is well settled that the delay cannot be condoned on the ground of equity and generosity. While proceeding with the prayer made it has to be kept in mind that expiration of the period of limitation prescribed gives a right to the adversary to treat the order as binding between the parties and this legal right provided by lapse of time should not be disturbed light heartedly. Similar view dovetails from the following authoritative pronouncements:-

11.              Hon’ble Supreme Court in Bikram Dass Versus Financial Commissioner and others, AIR 1977 Supreme Court 1221 has held as under:-

“Section 5 of the Limitation Act is a hard task-master and judicial interpretation has encased it within a narrow compass. A large measure of case law has grown around S.5, its highlights being that one ought not easily to take away a right which has accrued to a party by lapse of time and that therefore a litigant who is not vigilant about his right must explain every day’s delay.”

12.              In Pundlik Jalam Patil (dead) by LRS vs. Executive Engineer, Jalgaon Medium Project and Another, (2008) 17 SC 448, Hon’ble Supreme Court held as under:-

“…The evidence on record suggests neglect of its own right for long time in preferring appeals. The court cannot enquire into belated and stale claims on the ground of equity. Delay defeats equity. The court helps those who are vigilant and “do not slumber over their rights”.

13.              Hon’ble Apex Court in 2012(2) CPC 3 (SC)–Anshul Aggarwal  Vs. New Okhla Industrial Development Authority  observed as under:-

“It is also apposite to observe that while deciding an application filed in such cases for condonation of delay, the Court has to keep in mind that the special period of limitation has been prescribed under the Consumer Protection Act, 1986, for filing appeals and revisions in Consumer matters and the object of expeditious adjudication of the Consumer disputes will get defeated, if this Court was to entertain highly belated petitions filed against the orders of the Consumer Foras”.

 

14.              In view of the above, this Commission has to bear in mind that the object of expeditious disposal of consumer dispute would get defeated if such like applications filed on frivolous grounds are allowed. The law comes to the assistance of the vigilant and not of the sleepy.  This Commission has to examine whether delay in filing of the appeal has been properly explained or not. The true guide is whether the appellant has acted with reasonable diligence in the prosecution of its appeal.

15.              In the case in hand, the ground taken in the application is a sad commentary on the working of the employees of the appellant and this ground is manifestation of the laxity, negligence and inefficiency.  To accept such ground as sufficient cause for condonation of delay would tantamount to putting premium on the parties own acts of negligence and non challance.  So, this Commission does not find it a fit case to condone the delay of 181 days. Hence, the application for condonation of delay is dismissed.

16.              Even on merits, there is no force in this appeal. Indisputably, the complainant had purchased the insurance policy from the insurance company on November 17^th, 2010 and the same was got renewed continuously without any break. She was admitted in Fortis Memorial Research Institute, Gurgaon on May 18^th, 2013 and paid Rs.70,217/- on her treatment. As per treatment record issued from the Fortis Hospital, Renu Rastogi-complainant was admitted with the complaint of Fibroid Uterus bleeding on May 18^th, 2013. She underwent Dilation and Curettage (D&C) operation on May 18^th, 2013. She was diagnosed for said ailment in April, 2013 only. Prior to that she was neither diagnosed nor treated for any sub mucous fibroid polyp at all as is evident from Certificate Exhibit C-1 issued from Fortis Memorial Research Institute, Gurgaon, reproduced as under:-

“This is to certify that patient Mrs. Renu Rastogi, DOB – 27^th June 1958, wife of Late Sh. Naresh Kumar, came with complaint of Post Menopausal Vaginal Bleeding in April 2013. She underwent Hysteroscopic Polypectomy and D&C on 18/5/2013. She was diagnosed with the same in April 2013 only. Prior to that she was neither diagnosed nor treated for any gynaecological problem.

The asymptomatic fibroids in the uterus are coincidental findings which did not require any intervention neither at that time nor after till date.”

17.              In view of the above, it cannot be said from any angle that case of the complainant falls under Section 6 (D) of the insurance policy.  So it is held that the Insurance Company is liable to pay the benefits of insurance to the complainant. No case for interference in the impugned order is made out.

18.              Hence, the appeal fails and is hereby dismissed on both the grounds, that is, being barred by limitation as well as on merits.

19.              The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the complainant against proper receipt and identification in accordance with rules, after the expiry of period of appeal/revision, if any.

 

 

Announced: 12.09.2017

(Balbir Singh) Judicial Member

(Nawab Singh) President

 

CL