Chandigarh

StateCommission

A/350/2015

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

Versus

Sanjiv Gupta - Opp.Party(s)

S.C.Thatai, Nitin Thatai, Adv.

06 Jan 2016

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

UNION TERRITORY, CHANDIGARH

 

First Appeal No.	350 of 2015
Date of Institution	28.12.2015
Date of Decision	06.01.2016

1. Apollo Munich Health Insurance Co. Ltd., SCO No.50-51, 4^th Floor, Sector 34-A, Chandigarh.

2. Apollo Munich Health Insurance Co. Ltd., 2^nd & 3^rd Floor, iLABS Centre, Plot No.404-405, Udyog Vihar, Phase-III, Gurgaon-122016                     

                                   …..Appellants/Opposite Parties

Versus

Sanjiv Gupta S/o Sh. Rabinder Nath, R/o #264,
Sector-12, Panchkula, Haryana 134113.

                                       …..Respondent/Complainant                    

Appeal under Section 15 of the Consumer Protection Act, 1986.

BEFORE:  JUSTICE JASBIR SINGH (RETD.), PRESIDENT.

                 MR. DEV RAJ, MEMBER

                 MRS. PADMA PANDEY, MEMBER

 

Argued by:  Sh. Nitin Thatai, Advocate for the appellants.

                          

PER PADMA PANDEY, MEMBER

              This appeal is directed against an order dated 06.10.2015, rendered by District Consumer Disputes Redressal Forum-II, UT, Chandigarh (hereinafter to be called as the District Forum only), vide which, it allowed the Consumer Complaint bearing No.623 of 2014, filed by the complainant, with the following directions:-

“13.      In the light of above observations, we are of the concerted view that the Opposite Parties are found deficient in rendering proper service to the complainant. Hence, the present complaint of the Complainant is allowed qua OPs. The Opposite parties are jointly & severally directed as under:-

[a] To reimburse an amount of Rs.1,16,675/- incurred by the complainant on his treatment;

   [b] To pay an amount of Rs.25,000/- to the complainant as consolidated amount of compensation for causing mental agony and harassment on account of deficiency in service;

[c] To pay litigation expenses to the tune of Rs.10,000/-

                  The above said order shall be complied within 45 days of its receipt by the Opposite Parties; thereafter, they shall be liable to pay an interest @18% per annum on the amount of Rs.1,16,675/- and also on the compensation amount of Rs.25,000/- from the date of filing of the complaint till it is paid, apart from paying litigation expenses.” 

 

2. The facts, in brief, are that the complainant had been taking medical insurance cover for self and family continuously since March, 2007 from The New India Assurance Company Ltd. (Annexure-I). It was stated that on being lured by a representative of Opposite Parties for porting the existing Health Insurance Policy from New India Assurance Co. Ltd. to Apollo Munich Health Insurance Co. Ltd., the complainant was issued “Optima Restore Policy” in March, 2013 vide policy Annexure-II, after pre-policy Health Check-up & tests, valid from 30.03.2013.  It was further stated that the complainant was informed that the coverage’s and benefits of the previous policy would remain intact, since this is simply porting of the policy and he was shown that the policy clauses Section-4B, Section-4C and Section-4D related to pre-existing diseases had been waived off, in writing, on the policy document.
3.  It was further stated that, in September, 2014, the complainant was advised to undergo Cystoscopy and TURP surgical procedure for the treatment of LUTS (Lower Urinary Tract Symptoms) by Dr. Hemant Hardikar (Annexure-IV), and as such the complainant sought cashless treatment facility since Fortis Mohali is the empanelled network hospital of Apollo Munich Health Insurance Company, but the same was denied vide Annexure-V.  It was further stated that the complainant was hospitalized on 27.09.2014 and discharged on 29.09.2014, from Fortis Hospital, Mohali, after successful treatment and made the payments from his own pocket. Thereafter, the complainant filed a claim with the Opposite Parties, for reimbursement of the expenses incurred on the said treatment and also supplied all requisite documents, but the same was rejected by them, on the ground of non-disclosure of material facts about a pre-existing condition, vide letter dated 31.10.2014 (Annexure-VIII).  It was further stated that the requirement for the surgical procedure arose more than 18 months later i.e. in September, 2014, after having ported the policy from New India Assurance Company to Apollo Munich.  It was further stated that the aforesaid acts of the Opposite Parties, amounted to deficiency, in rendering service. When the grievance of the complainant, was not redressed, left with no alternative, a complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter to be called as the Act only), was filed.
4.  The Opposite Parties have filed joint reply and admitted the issuance of medical insurance policy to the complainant.  It was stated that alongwith the proposal form, the complainant also submitted a Portability Form.  It was further stated that the proposal was accepted on the standard rates, based on the information provided by the complainant and consequently, the policy, in question, was issued commencing from 30.03.2013 to 29.03.2014. It was further stated that the treatment undertaken by the complainant during the currency of the policy and payment thereof by the complainant, is also admitted.  It was further stated that the denial of cashless facility is also admitted.  It was further stated that, as the complainant has concealed the material facts about his prior medical history of Lower Urinary Tract Symptoms and Grade 1 Prostatomegaly since February, 2013, as available in the Prescription dated 26.02.2013 of Sai Clinic, at the time of entering into the contract of insurance with the Opposite Party Company vide proposal form dated 11.03.2013, the said insurance contract is void ab-initio and is not binding upon the Opposite Party Company.  It was further stated that the claim of the complainant was rightly rejected by the Opposite Parties and the policy was cancelled ab-initio, from the date of renewal, in view of non-disclosure by the complainant of his pre-existing disease in the proposal form.  It was further stated that there is no deficiency in service on its part, and the answering Opposite Parties had prayed for dismissal of the complaint.
5.  In the rejoinder, filed by the complainant, he reiterated all the averments, contained in the complaint, and repudiated those, contained in the written version of the Opposite Parties.
6. The parties led evidence, in support of their case.
7. After hearing the Counsel for the Parties, and, on going through the evidence, and record of the case, the District Forum, allowed the complaint, as stated above.
8. Feeling aggrieved, the instant appeal, has been filed by the appellants/Opposite Parties.
9. We have heard the Counsel for the appellants/Opposite Parties, at the preliminary stage, and have gone through the evidence, and record of the case, carefully.
10. After going through the facts of the case we are of the considered opinion that the appeal in the instant case deserves to be dismissed for the following reasons.
11. The Opposite Parties had denied the claim of the complainant, on the ground of non-disclosure of material fact at the time of porting of the policy in the month of March 2013, which is evident from the proposal form dated 11.03.2013, placed on record by the Opposite Parties. However, on perusal of the documents, it is clear that the said policy had already expired on 29.03.2014, whereafter, a fresh policy was issued by the Opposite Parties on 30.03.2014, which was valid upto 29.03.2015 with the exclusion of clauses Section 4B, Section 4C and Section 4D, related to pre-existing diseases which had been waived off in writing on the policy document (Annexure-OP 4). It was during the currency of the fresh policy, the complainant had lodged the claim in the month of September 2014. There is no documentary proof that the complainant while renewing the policy on 30.03.2014 had quoted any wrong information, which had warranted the Opposite Parties, for cancellation of the said policy.
12. Further, the Opposite Parties have not placed on record any copy of the proposal form, copy of disclosure/declaration form signed by the complainant, at the time of the renewal of the policy issued on 30.03.2014, during the currency at which the claim of the complainant had arisen, and furthermore, the reliance of the Opposite Parties on the documents, which is related to a previous policy, does not carry any weightage, since it has outlived its tenure/period. The Opposite Parties where definitely deficient in service in cancelling the policy, issued on 30.03.2014, on the ground of non-disclosure, since the Opposite Parties themselves have renewed the policy without demanding any disclosure or declaration, before the issuance of the said policy on 30.03.2014 and therefore they cannot blame the complainant for non-disclosure.
13.          For the reasons recorded above, the appeal, being devoid of merit, must fail, and the same is dismissed, at the preliminary stage, with no order as to costs. The order of the District Forum is upheld.
14.        Certified copies of this order, be sent to the parties, free of charge.
15.        The file be consigned to Record Room, after completion.

 

Pronounced.

06.01.2016                              

                                                      Sd/-

                        [JUSTICE JASBIR SINGH (RETD.)]

PRESIDENT

                                                                                    Sd/-

[DEV RAJ]

MEMBER

                                                                                     Sd/-

[PADMA PANDEY]

 MEMBER

Gp

 

                                STATE COMMISSION

FIRST APPEAL No.350 of 2015

(Apollo Munich Health Insurance Co. Ltd. & Anr. Vs. Sanjiv Gupta)

 

Argued by:

 

Sh. Nitin Thatai, Advocate for the Appellants/Opposite Parties.

 

Dated    the   6^th day of  January, 2016

                               

             Vide our detailed order of the even date, recorded separately, the appeal filed by the appellants has been dismissed, with no order as to cost and the order passed by the District Forum has been upheld.

 

Sd/-                  Sd/-                              Sd/-

(DEV RAJ) MEMBER	(JUSTICE JASBIR SINGH (RETD.)) PRESIDENT	(PADMA PANDEY) MEMBER

Gp