Haryana

StateCommission

A/657/2018

APOLLO MUNICH HEALTH INSURANCE CO. - Complainant(s)

Versus

SHRI MUNINDRA SEHGAL - Opp.Party(s)

SACHIN OHRI

28 Jan 2019

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                                                 

                                                         First Appeal No.657 of 2018

                                                 Date of Institution: 18.05.2018

Date of Decision: 28.01.2019

 

Apollo Munich Health Insurance Co. Ltd., Central Processing Centre, 2^nd & 3^rd Floor, iLABS Centre, Plot No.404-405, Udyog Vihar, Phase-III Gurgaon and Corporate Office: 1^st Floor, SCF 19, Sector-14, Gurgaon through Deepti Rustagi,Vice President-Legal & Compliance, Authorized signatory.

…..Appellant

Versus

Shri Munindra Sehgal s/o Sh. Shri Harish Sehgal R/o Aster 303, Omaxe RPS Green Valley, Sector 41-42, Faridabad.

                   …..Respondent

CORAM:             Mr. Ram Singh Chaudhary, Judicial Member.

 

Present:              Shri Sachin Ohri, Advocate for appellant.

                             Mr.Bhuwan Vats, Advocate for the respondent.

                                                   O R D E R

RAM SINGH CHAUDHARY, JUDICIAL MEMBER:

          Delay in filing the appeal is condoned for the reasons stated in the application filed for condonation of delay.

2.      The brief facts of the case are that complainant obtained health cover for himself and his family members from the opposite parties in the year 2011. The health policy covered the complainant alongwith family members from 13.09.2011 to 14.10.2016. Till 2015 the complainant paid premium on regular basis and during that period he claimed only Rs.35,000/-. The mother of the complainant suffered Bilateral Knee Osteoarthritis in the year 2016 and knee was replaced at Max Health Care Hospital, Delhi  He was entitled for cashless treatment as per the terms and conditions of the policy.    He approached O.P.No.1 for cashless treatment, but, O.P.No.1 repudiated the claim on 17.04.2016 as the claim lies under the exclusion category on account of non-disclosure of the same in the proposal form.  According to exclusion clause of section 6 of the policy, joint replacement was covered under the policy as long as insured has paid two premiums and if illness was pre existing then the period will be 36 months.  He requested the O.ps. to pay the claim, but, to no avail.  Thus there was deficiency in service on the part of the O.Ps.

3.      O.Ps. filed  reply controverting his averments.  O.Ps. alleged that  the complainant violated the terms and conditions of the insurance policy as he did not disclose  that her mother was having pre-medical history of Bilateral Osteoarthritis before signing the proposal form. The treating doctor gave a certificate that problem of osteoarthritis was for the past 5 years and x-ray report done in the year 2011 was shared with the insurance company.   The x-ray report  was one month prior to the date of the proposal form of 24.08.2011.  He has concealed the pre existing disease.  The claim was rightly rejected by the O.Ps. As per the terms and conditions of the policy, the complainant was not entitled for any claim.  Thus there was no deficiency in service on the part of the O.Ps.

4.      After hearing both the parties, District Consumer Disputes Redressal Forum, Faridabad (In short “District Forum”) allowed the complaint and  directed the insurance company to restore the said policy to its original terms and conditions alongwith the benefits due and to process the  claim of Rs.4,08,578/- and make payment accordingly.  The respondent insurance  company is also directed to pay to the complainant Rs.2200/- as compensation for causing harassment and mental agony alongwith Rs.2200/- as litigation charges.

5.      Feeling aggrieved therefrom, O.P No.1.appellant  has preferred this appeal.

6.      This argument have been advanced by Sh.
Sachin Ohri, the learned counsel for the appellant as well as Sh.Bhuwan Vats, the  learned counsel for the respondent. With their kind assistance the entire records as well as the original record of the District Forum including whatever the evidence has been led on behalf of  both the parties had also been properly perused and examined.

7.      While addressing the arguments, Sh. Sachin Ohri, the learned counsel for the appellant has referred to the report of the Radiologist Annexure A-5, wherein the complainant has been shown to have suffered the pre-existing disease on 21.07.2011, whereas the present policy was purchased on 13.07.2011 without disclosing her pre-existing disease and this fact finds further corroboration from Annexure A-9 a prescription given by the treating doctor of  AIIMS Hospital.  Apparently, on the basis of the perusal of report Annexure A-5 the complainant is suffering from osteoarthritis at the time of submitting the proposal form.  The specific clause was intentionally withheld which is most material fact for making disclosure at the time of furnishing all the details and submitting the proposal form.  Hence the learned District Forum has illegally allowed the complaint of the complainant for granting the amount of compensation as per the insurance policy, whereas the complaint as such, is not maintainable on account of suffering from pre-existing disease before purchasing the insurance policy and consequence thereto, the impugned order passed by the learned District Forum dated 21.03.2018 is set aside while accepting the appeal and the complaint stands dismissed.

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

 

January 28th, 2019                         Ram Singh Chaudhary,                                                                           Judicial Member                                                                                         Addl.Bench                 

S.K.