Delhi

East Delhi

CC/561/2013

PANKAJ KUMAR - Complainant(s)

Versus

THE FAMILY HEALTH PLAN - Opp.Party(s)

18 May 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

 

C.C. NO.  561/13

 

Shri Pankaj Kumar

S/o Shri Parkash Chand Bhardwaj

R/o 144 A, Hari Nagar Ashram

Near Ashram Chowk, Delhi – 110 014                …….Complainant

 

Vs.

 

1. The Family Health Plan Ltd.

Plot No. 8, 3^rd Floor Retail Business

Centre Nangai Rai, Opp. Janakpuri

D-Block, Delhi – 110 046

 

2. Apollo Munich Health Ins. Co. Ltd.

10^th Floor, Tower-B, Building No. 10

DLF Cyber City, DLF City Phase-II

Gurgaon, Haryana – 122 002                                           ….Opponents

 

 

Date of Institution: 12.07.2013

Judgment Reserved on: 18.05.2017

Judgment Passed on: 22.05.2017

 

CORUM:

Sh. Sukhdev Singh (President)

Dr. P.N. Tiwari  (Member)

Ms. Harpreet Kaur Charya (Member)

 

Order By : Sh. Sukhdev Singh (President)

 

 

JUDGEMENT

          This complaint has been filed by Shri Pankaj Kumar against the Family Health Plan Ltd. (OP-1) and Apollo Munich Health Ins. Co. Ltd. (OP-2) under Section 12 of the Consumer Protection Act, 1986. 

2.       The facts in brief are that the complainant Shri Pankaj Kumar purchased a Health Shield Insurance Policy on 05.12.2011 vide policy no. 110104/11051/1000259714-01 for the period 08.12.2012 to 07.12.2013 for a sum of Rs. 3,00,000/- by paying a consideration amount of Rs. 8,258/-.  This covered the health insurance of the complainant.  They gave only computerized policy without giving any terms and conditions alongwith the same on 16.04.2013, the complainant felt some uneasy and acute pain in his stomach and he was immediately taken to emergency section in the Holy Family Hospital, where he was examined by group of doctors and was shifted to operation theatre for removal of stone.  He remained in the hospital till 20.04.2013.  On his discharge, he was advised to take care at home and also for follow up.  Intimation of his hospitalization was given to the respondent.  They were requested to register the claim and to supply a copy form to pay the claim of the complainant.  All necessary claim papers duly completed alongwith admission and discharge summary, medical bills, prescription and test reports in original were submitted to the respondent for an amount of Rs. 67,119/-.  The complainant made personal visits and phone calls to settle the claim, but nothing was done. 

          It has been stated that the complainant was harassed.  No settlement has been made for three months which is stated to be deficiency in service on the part of respondent.  It has been stated that exclusion clauses have not been brought to the knowledge of the complainant.  Thus, the complainant has claimed a sum of Rs. 67,119/- on account of hospitalization with interest @ 24%; compensation amounting to Rs. 50,000/- on account of mental agony, pain and suffering with Rs. 25,000/- as litigation expenses.

3.       In reply of OP-2, they have taken various objections stating that as per the policy, the cashless request could not be processed as the complainant was admitted for the treatment of Calculus (stones) or urogenital system, which comes under two year exclusion under Section 6 C of the policy, whereas the policy of the complainant had not completed two continuous years.  It is stated that on the information, declarations, and details provided by the complainant, policy no. 110104/11051/1000259714 was issued for the sum assured as per PF, to the complainant/proposer for the period between 05.12.2011 to 04.12.2012. 

          Thereafter, upon the request of the complainant to renew the said policy, the same was renewed as policy no. 110104/11051/1000259714-01 from 08.12.2012 to 07.12.2013.  It has been stated that the policy kit containing all the relevant documents including the policy terms and conditions were duly sent and delivered to the complainant.  The complainant never approached to OP-2 stating that any information given in the documents in the policy kit was incorrect or any terms and conditions were not acceptable to him.  They have made reference to Section 6 C of the policy, which states that:

“The Illnesses and treatments listed below will be covered subject to a waiting period of 2 years as long as in the third Policy Year the Insured Person has been insured under an Easy Health Policy continuously and with any break:

1. Illnesses: arthritis if non infective; calculus disease of gall bladder and urogenital system; cataract; fissure/fistula in anus, hemorrhoids, pilonidal sinus, gastric and duodenal ulcers; gout and rheumatism; internal tumors, cysts, nodules, polyps including breast lumps (each of any kind unless malignant); osteoarthritis and osteoporosis if age related; polycystic ovarian disease; sinusitis and related disorders and skin tumors unless malignant;
2. Treatments: ………………………………………………………”         

          It has further been stated that the cashless request was received on behalf of the complainant from Holy Family Hospital, New Delhi on 17.04.2013 for the treatment of the complainant for Right Ureteric Calculus with Left Ureterocele with Left Ureteric Calculus for an estimated amount of Rs. 60,000/- with proposed line of treatment as Incision of Left Ureterocele with Left URSL with Right DJ stending.  The complainant  was treated for Right Ureteric Calculus with Left Ureterocele with Left Ureteric Calculus i.e. Uretric stones, which was an illness having a specific two years waiting period in the policy issued to the complainant from inception of the policy, which in this case was 05.12.2011.  As per the policy of the complainant was in its second year and had not completed the  said two years period within which the claim in question arose, same was excluded from coverage in terms of the policy. 

          It is stated that complainant had taken policy no. 110104/11051/1000259714 from OP-2 for the first time on 05.12.2011 and Section 6 C was applicable with two years exclusion from the date of inception of the policy with OP-2, whereas the cashless request was with regards to illness, which was specifically excluded for first two years of policy of the complainant.  Other facts have also been denied. 

          No WS was filed on behalf of OP-1.

4.       The complainant has filed rejoinder to the WS of OP, wherein he has controverted the pleas taken in the WS and reasserted his pleas.

5.       In support of its case, the complainant has examined himself on affidavit.  Though, he has not got exhibited any document in his testimony, but he has placed on record a bill issued by Holy Family Hospital for an amount of Rs. 67,119/- for the period from 16.04.2013 to 20.04.2013.  The receipt for this bill has also been placed on record.  Thus, the fact remains that complainant has paid an amount of           Rs. 67,119/- for his treatment.  Discharge summary of the hospital has also been placed on record showing that the complainant was treated for Left Ureterocele with Left Ureteric Calculus, letter showing denial of cashless has also been placed on record, which states that “Cashless facility was denied, as the present ailment was two years exclusion as per Easy Health Policy under section 4.a.2.

          In defence, Apollo Munich Health Insurance Co. Ltd. (OP-2) has examined Shri Sameer Bhatnagar, Vice President - Legal and Chief Compliance Officer, who has deposed on affidavit.  He has narrated the facts, which have been stated in the WS.  He has also got exhibited documents such as board resolution(Ex.R2-1), proposal form (Ex.R2-2), policy schedule (Ex.R2-3) and (Ex.R2-4) and copy of preauthorization form (Ex.R2-5).

6.         We have heard Ld. Counsel for the parties and have perused the material placed on record.  The only argument, which has been advanced on behalf of Apollo Munich Health Insurance Co. Ltd. (OP-2) has been that the complainant was treated for Right Ureteric Calculus with Left Ureterocele with Left Ureteric Calculus, which was having a waiting period of two years to be covered under the policy.  It has also been argued that only the cashless was denied. 

          On the other hand, Ld. Counsel for the complainant has argued that they have submitted the claim alongwith all the original documents and they were not heard anything about the claim.  He has further argued that the disease for which the complainant took the treatment was not having a waiting period of two years.  He has also argued that even if the cashless was denied, the same would have been the position with regard to their final claim.  Firstly, with regard to denial of claim, when they have denied cashless after invoking exclusion clause, the position will remain the same with regard to adjudication of the final claim.  The complainant is stated to have submitted the claim and no document has been placed on behalf of insurance company as to whether they have rejected or accepted the claim, the plea taken by the complainant that they have submitted their final claim has to be accepted. 

          Coming to the second argument with regard to exclusion clause, a look has to be made to the commencement of the policy and the exclusion clause. For this, testimony of Shri Sameer Bhatnagar, Vice President of OP-2 is to be scrutinized.  This witness has stated in his testimony in Para 8 of his affidavit that the complainant took the Easy Health Floater Standard policy having no. 110104/11051/1000259741 which commenced from 05.12.2011 to 04.12.2012.  He renewed the policy which commenced from 05.12.2012 to 04.12.2013.  Making reference to Section 6(c) of the policy, it has been stated that “Section 6(c) of the policy was reduced to one year (from two years waiting period as standard, it was reduced to one year) for all four insured”.  Thus, from this, it comes out that the waiting period of two years was reduced by the insurance company to one year under Section 6(c) of the policy. 

          The complainant remained admitted in the hospital from 16.04.2013 to 20.04.2013 in the second year of the policy.  When the insurance company has reduced the waiting period from two years to one year under Section 6(c) of the policy, their argument that the treatment taken by the complainant for Calculus disease of gall bladder and urogenital system was excluded under the exclusion clause as there was a waiting period of two years don’t hold good.  Thus, by reducing the waiting period of two years to one year, when the insurance company has given the benefit to the insured, later on they cannot take the plea that the diseases, which were mentioned under the exclusion clause Section 6(c) of the policy, will be made applicable to them.

          Thus, the treatment taken by the complainant does not fall under the exclusion clause as the insurance company himself has reduced the waiting period from two years to one year.  The claim rejected by the insurance company amounts to deficiency in service and the complainant was entitled for refund of the same.  When the insurance company has not processed the claim of the complainant and he has not been made known of the fate of his claim, certainly, he has suffered mental pain and agony, for which he has to be compensated. 

          In view of the above, it is ordered that the insurance company shall pay an amount of Rs. 67,119/- with interest @ 9% p.a. from the date of filing the complaint.  We further award an amount of Rs. 30,000/- towards compensation on account of mental agony, pain and suffering, which includes the cost of litigation also.  This order be complied within a period of 45 days.  If not complied, then Rs. 30,000/- shall also carry interest @ 9% p.a. from the date of order.

          Copy of the order be supplied to the parties as per rules.

          File be consigned to Record Room.

 

 

(DR. P.N. TIWARI)                                              (HARPREET KAUR CHARYA)

Member                                                                                Member 

 

           

            (SUKHDEV SINGH)

                                                      President