Karnataka

Chitradurga

CC/505/2019

Sri Virupakshappa.R.S - Complainant(s)

Versus

The Manager, Apollo Munich Health Insurance Com.Ltd., - Opp.Party(s)

Sri.H.Manjappa

25 May 2023

ORDER

COMPLAINT FILED ON:29/08/2019

DISPOSED ON:25/05/2023

 

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, CHITRADURGA.

C.C.NO:505/2019

DATED: 25^th May 2023

 

PRESENT: Kum. H.N. MEENA, B.A., LL.B., PRESIDENT

                  Smt. B.H. YASHODA, B.A., LL.B., LADY MEMBER        

  Sri. H.JANARDHAN, B.A.L., LL.B., MEMBER       

COMPLAINANT	Sri.Virupakshappa R.S.,           S/o Siddalingappa M.B.,           Agriculturist, R/O Banasihalli Village,           Doddaghatta Post, Hosadurga Taluk,     Chitradurga District.   (Rep by H.Manjappa, Advocate)
V/s
OPPOSITE PARTIES	The Manager, Apollo Munich Health Insurance Company Ltd., Central Processing Centre, 2nd & 3rd Floor, ILABS Centre, Plot No.104-105, Udyog Vihar, Phase No.3, Gurgaon-122016, Haryana State.   The Manager, Apollo Munich Health Insurance Company Ltd., No.317/A, 1st floor, Above HDFC Bank, 5th Block, Jayanagar, 9th Main Road, Near Adishwara Electric Show Room,     (Rep by Prasannakumar K, Advocate)

 

::ORDER::

 

By Sri. H.JANARDHAN, B.A.L., LL.B., MEMBER.

 

 

       

        This is a complaint filed by the complainant Under Section 12 Consumer Protection Act 2019 seeking relief against the OP to direct the OP to pay medical reimbursement amount of Rs.72,032/- along with interest at the rate of 12% per annum, direct the OPs to pay Rs.25,000/- towards mental agony and for such other  relief as this commission deems fit.

 

2. The brief facts of the complaint is as follows:

 

        Complainant had been issued a health under group insurance health plan under application No.20203732 which covered accidental and health insurance the said insurance service commenced from 07/08/2018 and issued policy kit and collected premium covering risk of complainants family member.  One Smt.A.T.Manjula was made as nominee.  Premium amount was received by the OP and was issued policy bearing No. 120100 / 12586/ 2018 / A012586 / PEO10766337 for the period commencing from 07/08/2018 to 06/08/2019.

 

3. Thereafter complainants wife was admitted to Narayana Health Mazumdar Sha Hospital for right Thigh Lipoma Excision on 08/04/2019 and she was operated on 09/04/2019 and discharge on 21/04/2019.  Medical expenses of Rs.72,032/- was incurred and complainant thereafter submitted application for reimbursement but OP company has repudiated the claim of the complainant for the reasons that illness which has a specific two years of waiting period as per the policy Under Section 5 A 2 but there is no such clause in the said section.  Which is contrary at the time of taking said policy this conditions were not brought to the notice of the complainant either from the Agent / Canara Bank or from the OP.  OP has repudiated the claim of the complainant without any reasonable cause as there is no violation of the conditions of the policy.  Moreover OP is under legal obligation to reimburse the amount spent for the treatment.  Complainant is an agriculturist and has borrowed the money from private money lenders on higher rate of interest.

 

4. Complainant also filed Petition before office of insurance ombudsman Bangalore the said authority ordered to file complaint Before The District Consumer Dispute Redressal Commission Chitradurga.  Op failed to settle claim of the complainant as OPs are not diligent in paying the insurance amount to the complainant which is nothing but deficiency inservice on the part of the OP and being aggrieved by the said act of the OP.  Hence complainant have filed this present complaint.

5. After insurance of notice to OPs 1 & 2 one Shri. P.K.Advocate filed vakalath for OP 1 & 2 and filed version in the version of OP 1 & 2 it is contended that complainant is not maintainable either in law or on facts.  Complainant does not disclose any cause of action against the OP.  The claim submitted by the complainant is for right thigh intravascular lipoma which has a specific 2 years of waiting period as per the policy and policy start date is 07/08/2018 and the date of admission is 19/04/2019 i.e., within 2 years from the date of inception therefore claim was repudiated Under Section (ii) of the policy thus in the absence of any cause of action against the OP present complaint is liable to be dismissed.

 

6. Since there is no deficiency in service on the part of the OP thus Hon'ble Commission has no jurisdiction to try and entertain the present complaint as complainant has miserably failed to demonstrate any deficiency in service nor has been able to prove any fault, interpretation, short coming or inadequacy in the quality, nature and manner of performance which is required to be maintained, in pursuance of a contract.  Since the treatment undergone by the wife of the complainant had waiting period of 2 years from the date of issuance of the policy.

 

7. The terms of the policy are in the nature of contract and their interpretation has to be made in accordance with the strict construction of the contract thus the words insurance contract was to be given paramount importance and interpretate as expressed without any addition deletion or substitution.  Complainant submitted a duly filed and signed enrolment form along with the requisite documents for procuring group assurance health plan from the OP.  On receipt of the enrolment form believing the information provided in the proposal form to be true and correct in all aspect the certificate of insurance was issued to the complainant on the basis of information in the proposal form.  OP company always sents the policy document along with copies of all the supporting documents to the policy holder to enable into go through the details in entirety ones again.  OP is regulated by the IRDA constituted under the act of insurance regulatory development authority act 1999 has been empowered to regulate promote and ensure orderly growth of the insurance business and has interalia the powers to control and regulate the rates, advantages terms and conditions that may be offered by insurer and protect the interest of policy holders in respect of matters concerning settlement of insurance claim and other terms and conditions of contract of insurance.  Every policy of the OP including the standard terms and conditions has gone through the scrutiny of IRDA and as such it demonstrates that the complainant is not entitled for any relief.

 

8. On 16/04/2019 cashless claim was received for patient Miss.A.T.Manjula from Muzumdar Sha Medical Center with date of admission as 17/04/2019 for Right Thigh intravascular Lipoma with estimated claim amount of Rs.75,000/- and the said cashless claim was rejected on the ground "Cashless facility cannot be granted as present element for which treatment is sought comes under 2 years exclusion list of policy terms and conditions hence the claim was repudiated with claim rejection letter dated:07/05/2019.  The rejection of the claim is as per the terms and conditions of the policy and further OP denies all other allegations made in complaint and prays dismiss the complaint with examplory cost.

09. Though sufficient opportunity was granted OP did not come forward to file Affidavit evidence hence Affidavit evidence of OP was taken as nil.

10. Written arguments of complainant is filed but OP did not choose to submit oral arguments and hence arguments of OP was taken as heard.

 

11. Points that arise for our consideration are as follows:-

1. Whether complainant proves deficiency in service on the part of the OP?
2. Whether complainant is entitled for the relief as sought in the complaint?
3. What Order?

12. Our answers to the above points are as follows:

1. Affirmative

2. Partly Affirmative

3. As per final Order  

:: REASONS ::

       13. On perusal of pleadings of both the parties it is not in dispute that complainant had obtained group insurance health plan under Application No.20203732 which covered accidental and health insurance. 

        14. The said insurance commenced from 07/08/2018 and also issued policy kit after collecting premium from the complainant covering risk of complainants family and one Smt.A.T.Manjula was made as nominee to the said insurance policy after collecting the premium from the complainant OP issued insurance policy bearing No.120100/12586/2018/A012586/PEO10766337. The said policy was valid from 07/08/2018 to 06/08/2019.  After insurance of the said insurance policy complainant was admitted to Narayana Health Mujumdar Sha Hospital for Right Thigh Lipoma on 08/04/2019 medical expenses incurred to the tune of Rs.90,032/-  as contemplated by complainant but OP could have paid medical expenses on non standard basis excluding non consumables as per  the medical insurance. Thereafter complainant submitted application for reimbursement but OP repudiated the claim of the complainant. 

15. Now the crux of the matter is to consider whether repudiation made by the OP is valid or not the complainant wife was admitted for Right Thigh Lipoma on 08/04/2019 within 6 months from the date of obtaining the insurance policy but as per policy terms and conditions Under Section 5 A (ii) there was specific clause that illness which has a specific waiting period of 2 years but within 2 years the complainant has undergone treatment for Right Thigh Lipoma.  Lipoma often show up after an injury though doctors don’t know whether thats what makes them form and inherited conditions can bring then on.  However Lipoma is not an illness as contemplated by the OP and as such when Lipoma is not an illness than the specific 2 years of waiting period is not necessary for the complainant.  Complainant have also submitted claim form to the OP along with necessary documents but without application of mind that Lipoma is not illness and Lipoma can be removed surgically and Lipoma removal procedures are safe and effective and patient can go home after treatment for one day.  As such the repudiation made by the OP on flimsy ground which is deficiency in-service.  Moreover insurance are taken by the general public knowing that it will come to their aid at the time of dire necessity if the insurance company repudiate on flimsy grounds then taking the insurance policy will be of no use. 

        16. Right Thigh Intravascular Lipoma is not an illness as contended by the OP and for which the treatment sought does not come under 2 years exclusion list of policy as Lipoma is not a illness but it is a heredity inherited condition can bring Lipoma as such OP are not right in repudiating claim of the complainant.  Hence OP is directed to reimburse an amount of Rs.50,000/- on non standard basis along with interest at the rate of 6% per annum from date of repudiation till realization.  Also OP is directed to pay sum of Rs.2000/- towards misery and suffering caused to the complainant and also complainant has engaged services of an advocate to contest the case on merits hence complainant is entitled for a sum of Rs.3000/-towards litigation cost.  And hence we answer point 1 and 2 as partly affirmative.

        For the foregoing reasons we proceed to pass the  following order.

 

:: ORDER ::

1. Complaint filed by the complainant Under Section 12 of the Consumer Protection Act is hereby partly allowed.

 

        2. OP is directed to reimburse an amount of Rs.50,000/- along with interest at the rate of 6% per annum from date of repudiation i.e., 07/05/2019 till realization within 30 days from the date of this order.

        3. Further, OP is directed to pay sum of Rs.2000/- towards misery and suffering caused to the complainant.

        4. OP is directed to pay a sum of Rs.3000/- towards litigation cost to the complainant.

 

      

(Dictated to the Stenographer, typed by him, the transcript corrected, revised and

then pronounced in the open commission by us on 25^th May 2023.)

 

Sd/-                                         Sd/-                                     Sd/-

                                                          LADY MEMBER                  MEMBER               PRESIDENT

 

 

-:ANNEXURES:-

 

 

Witness examined on behalf of Complainant:

 

PW-1: Sri.Virupakshappa R.S.  S/o Siddalingappa M.B. by way of affidavit evidence.

 

Witness examined on behalf of Opponents:

 

Nil

 

 

 

 

 

 

Documents marked on behalf of Complainant:

 

01	Ext-A-1:-	Appollo Munich Health Insurance Policy Kit Dated: 27/02/2020
02	Ext-A-2:-	Appollo Munich Health Insurance Rejection Letter Dated:07/05/2019
03	Ext-A-3:-	In the Office of the Insurance Ombudsman Bangalore Petition Copy dated:25/06/2019.
04	Ext-A-4:-	Office Of the Insurance Ombudsman (Karnataka) Policy Letter dated:13/07/2019.
05	Ext-A-5:-	Indian Postal Acknowledgement dated:01/07/2019.
06	Ext-A-6:-	Narayana Health Discharge Order letter dated:21/04/2019.
07	Ext-A-7:-	Narayana Health Mazumdar Shaw Medical Center OP Case Sheet dated:17/04/2019.
08	Ext-A-8:-	Original Bills of City Central Hospital and NH Mazumdar Shaw Medical Center

 

Documents marked on behalf of opponent:

 

Nil

         Sd/-                                         Sd/-                                     Sd/-

  LADY MEMBER                   MEMBER                     PRESIDENT