DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Surinder Singh Joshi, Advocate, R/o Kothi No.10, Sector 8-A, Chandigarh.

              ---Complainant

Vs.

1]   The Apollo Munich Health Insurance Company, Near Mukat Hospital, Sector 34-A, 2^nd Floor, Chandigarh, through its Manager.

2]   The Apollo Munich Health Insurance Company, 10^th Floor, No.10, Tower-B, DLF City, Phase-II, Gurgaon – 122 002, through its Managing Director. 

3]   The Apollo Munich, General Manager Health Insurance Co., Near Mukat Hospital, Sector 34-A, IInd Floor, Chandigarh.

4]   The Apollo Munich Health Insurance Company, 10^th Floor, No.10, Tower-B, DLF City, Phase-II, Gurgaon – 122 002. 

---- Opposite Parties

BEFORE:   MRS.MADHU MUTNEJA            PRESIDING MEMBER

SH. JASWINDER SINGH SIDHU    MEMBER

Argued By:    Sh. Gaurav Bhardwaj, Counsel for Complainant.

              Sh. R.S. Dhull, Counsel for Opposite Parties.

PER MADHU MUTNEJA, PRESIDING MEMBER

1.          The Complainant had taken a Health Insurance Policy from the Opposite Parties, valid from 1^st Sept. 2011 to 31^st Aug. 2012. On 08.10.2011 an operation for colostomy closure was performed in the Land Mark Hospital, Chandigarh for which the Complainant remained admitted in hospital from 08.10.2011 to 11.10.2011. The Complainant had incurred an amount of Rs.1,21,006.25P for the operation & medical treatment, expenses and hospital charges. However, when the Complainant approached the Opposite Parties for making payment of the amount, the claim was denied due to the following reasons:-   

“1)     The submitted claim is for the treatment of a disease/ symptoms which has been started before the start of the policy with us. As per the terms and conditions of the policy and pre-existing condition will not be covered until 36 months of continuous coverage with us. The disease/ symptom started on May 2011 and the policy start date is 01 Sep 2011. Hence we regret to inform you that your claim is repudiated under Section 6) clause d) of the Policy.”

          The Complainant has thus filed this complaint with a prayer for payment of the amount incurred on the treatment, along with interest and costs.

2.          Notice of the complaint was sent to Opposite Parties seeking their version of the case.

3.          Opposite Parties in their joint reply have maintained that at the time of receiving the proposal form, the Complainant was specifically told that it was subject to policy terms and conditions (Annexure R-1 and R-2). As per Section 6(d) of the terms and conditions of the policy, certain pre-existing conditions were not covered until 36 months of continuous coverage had elapsed since the inception of first easy health policy. As per the prescription of the treating doctor dated 01.11.2011, the admission in the hospital was for colostomy closure and the conditions thereof started in May, 2011. The first policy inception date is 01.09.2011. Hence, the claim was rightly rejected by the answering Opposite Parties. The terms and conditions of the policy and certificate issued by Dr. S.M. Bose dated 011.2011 (Annexure R-3 and R-4) make the entire position clear. It is asserted that the treatment is regarding colostomy closure as the Complainant had taken treatment for Sigmoid Loop Colostomy on 28.05.2011. Opposite Parties have stated that the claim was rightly rejected as per repudiation letter dated 26.03.2012 (Annexure R-6). Opposite Parties have therefore prayed for dismissal of the complaint with costs.

4.          Parties were permitted to place their respective evidence on record, in support of their contentions.

5.          We have heard the learned counsel for the parties and have perused the record.

6.          The treatment relates to Colostomy Closure performed on the Complainant on 08.10.2011. As per the medical history of the Complainant placed on record, he was suffering from large abscesses in the perianal region due to which I&D with debridement was done on 26.05.2011. Sigmoid Loop Colostomy was also done on 28.05.2011. This treatment relates to creation of an alternate passage for passing of stool as the perianal region of the patient is inflamed due to abscess & puss. Normal passage of stool is not only painful but also harmful. The creation of the alternate passage helps to heal the anal tract and perinium. I&D debridement would mean cutting the top layer of the perinium so as open the wound for faster healing. The Complainant has taken the Health Insurance Policy from the Opposite Parties in Sept. 2011 after this treatment was done in May, 2011.

7.          The proposal form signed and filled by the Complainant and placed on record at Annexure R-1 by the Opposite Parties does not give any mention of any earlier ailment suffered by the policy holder or any treatment taken for the same. Clause 6 of the Proposal Form, relates to Medical and Life Style Information. In Section A, B and C, the Complainant has written ‘No’ against any disease suffered. He has not referred or mentioned any earlier ailment or any surgery done earlier as ‘N’ has been written against all heads.

8.          The procedure performed on the Complainant in Oct. 2011 is with regard to closure of colostomy after the colon has healed. As per Annexure A-7, which is a certificate of Dr.S.M. Bose placed on record by the Complainant, Mr. Surinder Singh Joshi had been under treatment for large abscesses of both sides around the anal opening for which relevant procedures had been conducted on the patient in May, 2011. After the distal cologram was performed as per the certificate dated 19.08.2011 on record at Pg.26 the Rectum and Sigmoid colon was found to be normal and no obstruction was seen. The Complainant accordingly, got the surgery for closure of colostomy as his perianal region has now healed. The Opposite Parties while relying on Section 6 (d) of the terms & conditions of the Policy have chosen to repudiate the claim of the Complainant. The condition reads as under: - 

6(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 a waiting period of 1 year will apply, if the Insured Person:-

i)       was insured continuously and without interruption for at least 2 years under another Indian Insurer’s individual health insurance policy for the reimbursement of medical costs for inpatient treatment in a Hospital, and

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

9.          We do not think that the decision taken by the Opposite Parties is wrong, as the operation perform in Oct.2011 is an aftermath of the treatment taken in May, 2011. The treatment of May, 2011 would not have come under the pre-existing condition, but the later treatment of Oct. 2011, for which the present complaint has been filed, is definitely a condition covered under Section 6(d) of the terms & conditions of the policy, reproduced above, which relates to pre-existing disease. The claim therefore, has rightly been declined.  

10.        Hence, finding no merit in the complaint. We dismiss it with no order as to costs.

11.        The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

21^st May, 2013                            

Sd/-

(MADHU MUTNEJA)

PRESIDING MEMBER

Sd/-

(JASWINDER SINGH SIDHU)

MEMBER