Delhi

North

RBT/CC/255/2022

ASUTOSH LOHIA - Complainant(s)

Versus

APOLLO MUNICH HEALTH INSURANCE - Opp.Party(s)

19 Mar 2024

ORDER

District Consumer Disputes Redressal Commission-I (North District)

[Govt. of NCT of Delhi]

Ground Floor, Court Annexe -2 Building, Tis Hazari Court Complex, Delhi- 110054

RBT Consumer Complaint No.:255/2022

In the matter of

 

Sh. Ashutosh Lohia

S/o Sh. K. C. Lohia,

W-141, 3^rd floor,

Greater Kailash, Part-1,

Delhi-1100048.                                    …                                   Complainant

                                                          Vs

M/s Apollo Munich Health Insurance,

Pitampura Sales Office,

103, Upper Ground floor,

ITL Twin Towers,

Netaji Subhash Place,

Ring Road, Pitampura,

New Delhi-110034.                  

 

Also at:

1^st floor, 6 & 7,

B. K. Roy Court,

Asaf Ali Road,

New Delhi-110002.                                      …                                     Opposite Party     

ORDER

19/03/2024

 

Ashwani Kumar Mehta, Member:

 

1.       The Complainant has filed this complaint under Section 12 of the Consumer Protection Act, 1986 before Hon’ble DCDRC-V, Shalimar Bagh and was assigned the Consumer Complaint No.164/2018 and it was further transferred to this Commission by the Hon’ble Delhi State Consumer Disputes Redressal Commission vide its order dated No.F.1/SCDRC/Admn/Transfer/20222/330 dated 16.04.2022 and accordingly, this complaint was registered as RBT/CC No.255/2022 in this Commission.

 

2.       The brief details of facts, as alleged by the Complainant in the Complaint in hand, are that:-

 

1. the Complainant had purchased a Health Insurance Policy Bearing No.110101/11121/AA00185889 dated 08.02.2015 from OP for himself and his family members comprising of his wife and 2 minor children on payment of premium of Rs.16,642.76/- (Rupees Sixteen Thousand Six Hundred  Forty Two and Paisa Seventy-Six Only) for Basic Sum Insured Rs. 5,00,000/- (Rupees Five Lakh Only).  The said policy was valid from 16:10 hrs on 08.02.2015 upto 24:00 hrs on 07.02.2016. Unfortunately, during the existence of the policy period, the complainant started having lower back pain and consulted his family doctor Dr. Anil Gomber on 10.12.2015 whereupon he was prescribed some medicines and was advised to come back for review. Copy of the prescription dated 10.12.2015 of Dr. Anil Gomber has been annexed with the complaint as Annexure P-2.
2. the pain of the complainant worsened with time and  thus, he was advised to get a MRI of Lumbo-Sacral Spine which he got done on 02.01.2016. The MRI report dated 02.01.2016 as well as the bill for the same has been annexed with the complaint as Annexure P-3 (Colly).
3. the complainant consulted Dr. Anil Gomber with the MRI report on 02.01.2016 itself and was advised further medication and rest for 3 days. The complainant was further advised by Dr. Anil Gomber to consult Dr. Anil Sachdev in Max Hospital, Pitampura. True copy of the prescription dated 02.01.2016 of Dr. Anil Gomber has been annexed with the complaint as Annexure P-4.
4. on the very next day i.e. 03.01.2016, the complainant visited the OPD of Max Hospital, Pitampura and consulted Dr. Anil Sachdev wherein he was prescribed medicines and complete bed rest. True copy of the prescription dated 03.01.2016 of Dr. Anil Sachdev as well as the invoice has been annexed with the complaint as Annexure P-5.
5. the condition of the complainant deteriorated and the complainant was in excruciating pain and had not been able to pass urine since the afternoon of 03.01.2016 and thus, was admitted in emergency of Vinayak Hospital, Model Town, Delhi in the night of 03.01.2016 where complainant was managed with some drugs overnight and was advised to undergo Lumbar Canal Stenosis. The family of the complainant, on advice, thus, approached Dr. Rana Patir, Dept of Neurology, Fortis Hospital, Gurgaon for an opinion on 04.01.2016 morning and accordingly, on the advice of Dr. Rana Patir, Complainant was got discharged from Vinayak Hospital on the morning of 04.01.2016 and was directly admitted to Fortis Hospital, Gurgaon on 04.01.2016 itself by an ambulance from Vinayak Hospital. True copy of the discharge summary of the complainant of Vinayak Hospital, lab reports and bills have been annexed with the complaint as Annexure P-6.
6. The complainant made a payment of Rs.6540/- for the hospitalization at Vinayak Hospital and an amount of Rs.581/- towards the medicines purchased between 03.01.2016 and 04.01.2016.
7. The complainant/his attendant approached the counter of the OP – Apollo Munich at the Fortis Hospital, alongwith all the documents including the earlier doctor prescriptions, medical reports and hospitalization details on the date of admission i.e. 04.01.2016 itself to seek pre-authorization request. All the documents and details were furnished to the OP and the complainant was informed that his request for cashless authorization was being examined and will be intimated soon.
8. The surgery of the complainant was initially scheduled for the early morning of 05.01.2016, however, the OP did not provide any definitive answer to the complainant till late evening and thus, the complainant having no choice, made payment to the hospital in order to undergo the emergency procedure. The complainant and attendant again approached the counter of the OP who informed that they were still investigating the case of the complainant and either way, even if the cashless hospitalization authorization is not granted, they would be entitled to reimbursement.
9. In the evening of 05.01.2016 at 05:45pm, one Mr. Sumit Sharma, Investigator of the OP company handed over a letter to the complainant/his family of even date asking for written statement regarding the disease and past consultant doctor prescription. Immediately, the wife of the complainant responded with written letter dated 05.01.2016 at 6pm detailing out the previous history of the disease as well the previous doctor details and reiterated that the documents had already been provided. True copies of the said letter dated 05.01.2016 have been annexed with the complaint Annexure P-7.
10. This letter of the complainant’s wife was written under protest as the request for cashless hospitalization had not been allowed and the OP investigator and officials were stalling the process by making vague statements that they were still investigating and were in need of further documents. The OP Insurance Company had a counter in the hospital premises itself and all the documents relating to the complainant were easily available to them and in fact, were made available on the 04.01.2016 itself.
11. The complainant on 05.01.2016, underwent L5-S1 micro-disectomy and decompression through METRx tubes system under GA at Fortis Hospital, Gurgaon and was discharged on 06.01.2016. The discharge summary as well as the lab reports of the hospitalization stay of the complainant from 04.01.2016 to 06.01.2016 has been annexed with the complaint as Annexure P-8.
12. The bill for this period of hospitalization amounted to Rs.2,48,090/- which was paid by the complainant. True copy of the final bill as well as the detailed bill has been annexed with the complaint as Annexure P-9. Counselling form has also been annexed with the complaint as Annexure P-10.
13. The complainant also went for a follow up review check-up post surgery on 14.01.2016. The copy of the prescription has been annexed with the complaint as Annexure P-11.
14. Therefore, the complainant submitted the requisite Claim Form dated 14.01.2016 to the OP office at Pitampura Delhi against acknowledgement stamp on 15.01.2016, claiming the total amount of Rs. 2,61,125/- alongwith all the documents as desired. True copy of the Claim Form dated 14.01.2016 has been annexed with the complaint as Annexure P-12.
15. The OP sent a “Query Letter” dated 23.01.2016 for Claim ID 359939/1 to the complainant in respect of the claim raised for Vinayak Hospital amounting to Rs.13,285/- stating that “We are currently processing your claim and require additional documents to arrive at a decision on the same. We request you to submit the following documents...xxxxxxx.”. True copy of the letter of the OP dated 23.01.2016 has been annexed with the complaint as Annexure P-13.
16. The complainant replied vide letters dated 25.01.2016, in respect of the Claim ID No.359939 and Claim ID No. 358589 hand delivered against acknowledgement stamp of 28.01.2016, answering the query put forth alongwith another set of all the requisite documents. True copy of the said letters dated 25.01.2016 have been annexed with the complaint as Annexure P-14.
17. Thereafter, the OP sent identical query letters dated 03.02.2016 titled as “Query letter” and letter dated 17.02.2016 titled as First Reminder Letter and letter dated 25.02.2016 titled as Final Reminder Letter in respect of the Claim ID No. 359939/1 where the claimed amount was Rs.13,285/-, seeking the same queries which were already answered by the complainant vide letter dated 25.01.2016. True copies of the said letters have been annexed with the complaint as Annexure P-15 (Colly).
18. In respect of the Claim ID No. 358589/1, where the claimed amount was Rs.2,54,585/-, the OP sent identical query letters dated 06.02.2016 titled as Reminder Letter, letter dated 15.02.2016 titled as “Final Reminder Letter” and a “Closure letter” dated 23.02.2016 wherein it was stated that “This is to inform you that, inspite of repeated reminders sent to you on 22 Jan, 06 Feb and 15 Feb 2016, we have still not received the pending documents which are necessary to process your claims. Hence, we regret to inform that your claim has been closed. “True copies of the said letters have been annexed with the complaint as Annexure P-16 (Colly).
19. In the meanwhile, as the existing health insurance policy of the complainant was to lapse, the complainant renewed the same on the request of the OP and the OP issued Policy Bond for the period 15.02.2016 to 14.02.2017. The said policy was further (once again) renewed on 15.02.2017 to 14.02.2018. True copy of the Policy renewal letters and schedules have been annexed with the complaint as Annexure P-17 (Colly).
20. The complainant received the Closure Letter dated 23.02.2016 on 02.03.2016, and immediately sent an email on 02.03.2016 to the OP stating that the claim had been wrongly closed and that the pending documents had already been submitted to the OP office way back on 28.01.2016 against proper receipt. True copy of the email dated 02.03.2016 has been annexed with the complaint as Annexure P-18.
21. The OP sent another “Closure letter” dated 04.03.2016 in respect of the Claim ID 359939/1 wherein it was stated that “This is to inform you that inspite of repeated reminders sent to you on 2 Feb, 17 Feb and 25 Feb 2016, we have still not received the pending documents which are necessary to process your claims. Hence, we regret to inform that your claim has been closed.” True copy of the said letter dated 04.03.2016 has been annexed with the complaint as Annexure P-19.
22. The OP instead of rectifying the mistakes at its end and processing the claim, sent another “Query Letter” dated 09.03.2016 in respect of the Claim ID 358589/1 stating that “We are currently processing your claim and require additional documents(s) to arrive at a decision on the same. We request you to submit the following documents…xxxxx”. This was the same list of documents which had already been submitted to the OP way back on 28.01.2016. True copy of the said letter dated 09.03.2016 has been annexed with the complaint as Annexure P-20.
23. However, to set the record straight, the complainant vide letter dated 28.03.2016, submitted the requisite documents which answers to the query put forth by the OP again in respect of both the Claim IDs 359939 and 358589. True copy of the letter dated 28.03.2016 has been annexed with the complaint as Annexure P-21.
24. In response, the OP again sent a reminder letter dated 31.03.2016 identical to the previous letters seeking the same documents. True copy of the letter dated 31.03.2016 has been annexed with the complaint as Annexure P-22.
25. This was followed with a closure letter sent by OP via email on 12.04.2016. True copy of the email dated 12.04.2016 has been annexed with the complaint as Annexure P-23.

 

3.       It has been alleged that the complainant has further undergone physiotherapy and rehabilitation therapy and has accordingly further increased post-hospitalization expenses for an additional sum of Rs.1,10,000/- (Rupees One Lakhs Ten thousand Only).

 

4.       It has further been alleged that the OP has wrongly denied the claim amount of the complainant on the most arbitrary and vague reasoning of “non-submission of documents” which is false as the complainant has submitted all the documents four times, firstly with the claim form itself, secondly on their request on 28.01.2016 (with acknowledgement receipt) and thirdly on 28.03.2016 (with acknowledgement receipt) and fourthly via email. The above series of events, demonstrates that the OP has malafidely denied the claim for both the hospitalizations of complainant for the period for which the policy was very much valid and in existence. The illegal, malafide and arbitrary action of the OP is writ large as at first they did not approve the request for pre- authorization till the last minute when the complainant had to undergo surgery in an emergency and thereafter assured the complainant that reimbursement shall be done. And once the claim forms with all the documents were submitted, OP in the most stereotypical manner without any application of mind, has been sending carbon copies of the same letter stating that they have not received the documents. Time and again, the documents have been submitted by the complainant in respect of his claims to the OP but to no avail.

 

5.       Therefore, the Complainant has filed this complaint praying to pass an order to:-

1. Direct the OP to pay to the complainant an amount of Rs.2,61,125/-towards the mediclaim expenses actually incurred by the complainant during the subsistence of the policy which have been denied by the OP alongwith interest @ 18% per annum till actual payment is made;
2. Direct the OP to pay an amount of Rs.1,00,000/- to the Complainant towards compensation for mental agony, ordeal, tension and harassment caused to the complainant due to the grave deficiency of services and unfair trade practices on behalf of the OP under the Consumer Protection Act;
3. Direct the OP to pay an amount of Rs. 1,00,000/- (Rupees One Lakh) as cost of legal proceedings;
4. Pass any other such order(s) in favour of the complainant and against the OP in the facts and circumstances of the case as deemed fit and necessary in the interest of justice.

 

6.       Accordingly, notice was issued to the OP to defend the complaint before this commission but the OP neither appeared nor did send any communication despite service of the notice. Since the OP chose not to appear despite service, has been proceeded Ex-parte.

7.       The Complainant has filed evidence, written arguments and has also led oral arguments. The OP did not participate in the oral arguments proceedings also.  The Complainant has also filed following judgments alongwith written arguments in support of the allegations levelled against the OP:-

1. Sunil Sharma V. National Insurance Company Ltd [II(2015)CPJ46(Del)] wherein it has been observed that “Insurance Companies to be honest & forthright in its approach while settling an insurance claim, factors which are material land germane should be given importance. Insurance claims cannot be rejected on flimsy and technical grounds otherwise confidence of people in insurance companies would be deeply eroded”.
2. Shriram General Insurance Co. Ltd. v. Ramcharan Dhobi [MANU/CF/0032/2017] where it has been observed that “Insurance Claims cannot be rejected on purely technical grounds like delay in intimation or submission of documents.”

 

8.       The Complainant has also referred IRDA Circular No. IRDA/HLTH/MISC/CIR/216/09/2011 dated 20.09.2011 wherein it has been stated that “the insurers' decision to reject a claim shall be based on sound logic and valid grounds.

 

9.       Therefore, the complaint has been examined on merits on the basis of the documents/evidences & material available on records and it has been observed that :-

i.       The OP has not granted “pre- authorization of treatment”  without any cogent reasons till the last minute when the complainant had to undergo surgery in an emergency and the complainant was compelled to pay for the treatment inspite of having valid Health Insurance Policy.

ii.      Thereafter, the complainant had filed claim of reimbursement of expenses, the OP  denied the claim of the complainant on the ground of “non-submission of documents” whereas  all the documents were submitted by the complainant to  OP four times, firstly with the claim form, secondly on 28.01.2016 (with acknowledgement receipt) and thirdly on 28.03.2016 (with acknowledgement receipt) and fourthly via email which is sufficient to conclude that the OP has arbitrarily and illegally denied the claim on flimsy ground for both the hospitalizations of complainant for the period for which the policy was very much valid and in existence.

3.  

iv.      It is also relevant in this case that all the insurance company are bound to observe the guidelines issued by IRDA vide Circular No. IRDA/HLTH/MISC/CIR/216/09/2011 dated 20.09.2011 wherein it has been stated that:-

“the insurers' decision to reject a claim shall be based on sound logic and valid grounds. It may be noted that such limitation clause does not work in isolation and is not absolute. One needs to see the merits and good spirit of the clause, without compromising on bad claims. Rejection of claims on purely technical grounds in a mechanical fashion will result in policyholders losing confidence in the insurance industry, giving rise to excessive litigation. Therefore, it is advised that all insurers need to develop a sound mechanism of their own to handle such claims with utmost care and caution. It is also advised that the insurers must not repudiate such claims unless and until the reasons of delay are specifically ascertained, recorded and the insurers should satisfy themselves that the delayed claims would have otherwise been rejected even if reported in time."

v.       In Para 25 of the complaint, it has been alleged that the complainant has further undergone physiotherapy and rehabilitation therapy and has accordingly further increased post-hospitalization expenses for an additional sum of Rs.1,10,000/- (Rupees One Lakhs Ten thousand Only) but no claim for this expenditure appears to have been filed as per the documents submitted with the complaint. It has also been found that the Complainant has not made any prayer in this regard. As such, the Complainant is at liberty to file this claim with the OP within 30 days from the date of receipt of this order, in case the claim for these expenses has not been filed in the past.

 

 

10.     In view of the above facts and observations, we are of the considered view that the OP has repudiated/closed the valid claim in unjustified way on flimsy grounds ignoring the facts that the Complainant has provided all the required documents to the OP under proper acknowledgement stamp which amounts to deficiency in service and unfair trade practices on the part of the OP. It is also apparent that the arbitrary and unjustified act of repudiation of the claim by the OP, has caused harassment, mental agony & pain to the complainant. Therefore, we feel appropriate to direct the OP (M/s Apollo Munich Health Insurance Co. Ltd.) to pay the complainant:-

1. an amount of Rs.2,61,125/-(Rupees Two Lakh Sixty-One Thousand One Hundred Twenty Five Only), with interest at the rate of 9% p.a. from 15.02.2016 (after 30 days from the date of filing the claim with OP) till the date of the payment;
2. an amount of Rs.1,00,000/- towards compensation for mental agony, pain and harassment caused due to the deficiency of services.

11.     After observing the conduct of the OP in this matter, we consider it proper to impose cost of Rs.50,000/- (Rupees Fifty Thousand Only) upon the OP in addition to the directions given in Para 10 above. Out of the above cost imposed, Rs.25,000/- shall be paid to the Complainant and Rs.25000/- shall be deposited in the “ State Consumer Welfare Fund (L/Aid), SBI Account No.00000010310544717, IFSC No.SBIN0001187” within 30 days

 12.    It is clarified that if the abovesaid amount is not paid by the OP to the Complainant within 30 days from the date of receipt of this order, the OP shall be liable to pay interest @12% per annum from the date of expiry of 30 days period.

13.     Order be given dasti to the parties in accordance with rules. Order be also uploaded on the website. Thereafter, file be consigned to the record room.

 

ASHWANI KUMAR MEHTA                                          HARPREET KAUR CHARYA

               Member                                                                                     Member          

         DCDRC-1 (North)                                                                DCDRC-1 (North)

 

 

DIVYA JYOTI JAIPURIAR

President

DCDRC-1 (North)