DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

BATHINDA

C.C. No. 03 of 02-01-2019

Decided on : 08-11-2021

Hardeep Singh aged about 58 years, S/o Pal Singh R/o Near Old Hospital, Opposite Nagar Panchayat Office, Bhagta Bhai Ka, District Bathinda.

........Complainant

Versus

1. Apollo-Munich Health Insurance Co. Ltd., Central Processing Centre : ILABS Centre, 2^nd & 3^rd Floor, Plot No. 404-405, Gurgaon 122 016 (Haryana), through its Chairman-Cum-Managing Director/Incharge.

2. MS Equitas Small Finance Bank Ltd., Branch Office : Clock Tower, Near ICICI Bank, Bibiwala Road, Bathinda, through its Branch Manager (Deleted vide order dated 3-1-2019)

.......Opposite parties

Complaint under Section 12 of the Consumer Protection Act, 1986

QUORUM

Kanwar Sandeep Singh, President

Sh. Shivdev Singh, Member.

Smt. Paramjeet Kaur, Member

Present

For the complainant : Sh. Rakesh Kumar Mangla, Advocate.

For opposite parties : Sh. Varun Gupta, Advocate, for OP No. 1.

OP No. 2 deleted

ORDER

Kanwar Sandeep Singh, President

1. The complainant Hardeep Singh (here-in-after referred to as complainant) has filed this complaint U/s 12 of Consumer Protection Act, 1986 (Now C.P. Act, 2019, here-in after referred to as 'Act') before this Forum (Now Commission) against Apollo-Munich Health Insurance Co. Ltd., and another (here-in-after referred to as opposite parties).

2. Briefly stated, the case of the complainant is that the opposite party No.1 provides services of health/medi-claim policies against consideration and opposite party No. 2 is a banking company. Both the opposite parties are service oriented institutions. The opposite party No. 2 has its tie-up with opposite party No. 1 for the sale of their various health insurance policies.

3. It is alleged that complainant and his wife Surinder Kaur have their joint bank account no. 100002568660 with opposite party No.2. The officials of opposite party No. 2 approached the complainant to sell the mediclaim policy of opposite party No.1 to complainant and allured him that in the proposed policy the spouse of the complainant shall also be insured and in case of any health disorder or any minor or major operation, opposite parties shall indemnify the insured for the total expenses incurred thereon. The complainant agreed to purchase the proposed mediclaim policy of the opposite parties and paid requisite premium of Rs.11,575/- (amount of premium' was directly deducted from the aforesaid bank account of the complainant and his wife). The complainant and his wife was medically insured with the opposite parties for the period from 16-1-2018 to 15-1-2019 and opposite parties issued policy No. 140100/12586/2018/A008253/ PE00808888 and the policy type was 'Family Plan (2A)' under policy name 'Group Assurance Health Plan' against application No. EA00022623 for sum of Rs.5,00,000/-. The officials of opposite party No. 2 asked some personal information and questions about pre-existing disease etc., and the complainant cleared all the querries put by visiting officials. It was made clear to the visiting officials that about 7-8 years back, uterus of the wife of the complainant was got removed.

4. It is further alleged that that on 18-7-2018 at about 5.00 p.m., wife of the complainant felt chest pain. The complainant took his wife to Dr. Nirmal Singh, MBBS, Bhagta Bhai Ka who provided first aid and suspected some heart problem. Thereafter complainant took his wife to CMC, Ludhiana on the same day i.e.18-7-2018 and reached there at about 9.00 p.m. The attending Doctors of CMC, Ludhiana advised immediate admission. After admission, wife of the complainant was kept in ICU, where attending doctors asked some querries i.e. about previous heart related problem, BP problem, Diabetic problem and/or treatment thereof and complainant cleared all things. After, ECG and other requisite tests, attending doctor diagnosed it to be a minor attack which can be cured with the aid of medicines. The wife of the complainant was kept under observation for about two days and after treatment, when she was about to discharge on 20-7-2018, before discharge, final inspection was made by the attending doctor. She was told to walk slowly and little speedy. While doing so, she could not walk properly as she was having little limb ("lang marna"), as 3-4 months back, she fell down and suffered knee injury. The wife of the complainant was discharged on 20-7-2018 and the said hospital charged Rs.32,304/, which the complainant paid out of his own pocket. At the time of discharge, attending doctors advised for follow-up treatment.

5. It is also alleged that while preparing Discharge Summary, attending Doctors have mentioned about knee injury while making remarks `B/L Knee Osteoarthiritis. The complainant lodged claim with opposite party No. 1 and submitted original bills, discharge summary etc.. alongwith duly filled claim form.

6. It is further alleged complainant took his wife to the said hospital on regular intervals as advised by attending doctor for follow-up treatment and spent Rs.3189/-. In this way, the complainant spent Rs.37,489/- in all on the treatment of his wife. On receipt of claim, Investigator of opposite party No.1 visited the house of the complainant and obtained signatures on some papers.

7. It is pleaded that thereafter, opposite party No.1 vide mail dated 10-8-2018 requisitioned treatment/medical record pertaining to knee treatment and also requisitioned Treating Doctor Certificate mentioning the exact cause of chest pain. The complainant contacted attending doctor of CMC, Ludhiana for issuance of certificate and Dr. Rajneesh Calton, issued certificate/Treatment Summary dated 18-8-2018. The certificate was dispatched to opposite party No.1 vide speed post. Thereafter, wife of the complainant vide letter dated 23-8-2018 clarified to opposite party No. 1 that she suffered knee injury due to slip of foot and she was not got admitted in any hospital for the knee problem. She also made a request to opposite party No.1 to settle their claim at the earliest. The opposite party No.1 vide mail dated 2-12-2018 again requisitioned the aforesaid record but ultimately, the opposite partNo. 1 vide mail dated 17-12-2018, repudiated the genuine and lawful claim of the complainant on the flimsy grounds. Due to adamant attitude of the opposite parties, the complainant has suffered mental tension & agony, physical, social harassment.

8. On this backdrop of facts, the complainant has claimed Rs. 1,00,000/- as damages besides claim amount of Rs.37,489/- alongwith interest @ 18% p.a. and Rs.25,000/- as litigation expenses. Hence, this complaint.

9. Upon notice, the opposite party No. 1 put an appearance through counsel and contested the complaint by filing written reply. In written reply, the opposite party No. 1 submitted that opposite party No.1 is a Company duly incorporated under the Companies Act, 1956, having its CPC office at Gurgaon and is into business of providing Health Insurance Services. That present reply is being signed, verified and filed by Deepti Rustagi for and behalf of opposite party No.1. At the outset the opposite party No.1 deny in extensor and in extremity each and every allegation/averment/ contention/claim/demand, made by the applicantas being absolutely false, baseless, misconceived, untenable, incorrect and being made on surmises and conjectures.

10. The opposite party No. 1 raised preliminary objections that the complaint is not maintainable as the complainant has attempted to misguide and mislead this Commission and complaint involves disputed question of facts which cannot he determined in summary jurisdiction. That the complainant has not approached this Commission with clean hands and that prima facie no cause has arisen in favor of complainant. That intricate questions of law and facts are involved in this complaint which cannot be decided in summary manner. That the complaint is false, frivolous and vexatious and that the complainant is estopped from filing the complaint by his own acts, conduct, omissions and acquiescence.

11. Thereafter the opposite party No. 1 has mentioned factual matrix that every Proposer applies for a Policy by means of an application in the form of a customized Enrolment Form No, EA-00022623 wherein the Proposer is required to fill in material information in the said form. The opposite party received a duly filled and signed form from the complainant for availing health insurance Policy seeking to cover himself and her spouse namely Surinder Kaur. Believing the information and details provided by the Proposer including the medical history to be true and correct in all respects and giving due credence to the under writing norms of opposite parties, a Policy No.140100/12586/2018/A008253/PE00808888 was issued for sum assured of Rs. 5,00,000/- opted as per signed enrolment form No EA00022623, to the Proposer for the period between 16-01-2018 to 15-01-2019. The copy of Schedule bearing relevant details of the Policy along with policy bond having terms and conditions were duly sent and delivered to the Proposer. That the Opposite Party under reply had issued an Easy Health Group Insurance Policy to Equitas Small Finance Bank wherein the aforementioned Bank was the master policy holder and who would enroll Equitas Small Finance Bank customers under the ambit of Easy Health Group Insurance Policy. All the members enrolled in the policy would be subject to the terms and conditions of the Easy Ilealth Group Insurance Policy. The Policy kit containing all relevant documents was duly delivered to the complainant thereby giving an opportunity to the Complainant to verify and examine the benefits, terms and conditions of the policy taken by him.

12. It is pleaded that that a reimbursement claim was received on 06-08-2018, from the patient/insured Mrs. Surinder Kaur's hospitalization expenses incurred by her for the treatment of Acute Coronary Syndrome - Unstable Angina, from date of admission 18-07-2018 to date of discharge 20-07-2018. That from the section "Final Diagnosis" on first page of discharge summary it was noted that customer is also suffering from B/L osteoarthritis a degenerative condition that happens to form in a patient over the years as, the second page of discharge summary under section "course in the hospital" stated that - "patient who is a known case of Osteoarthritis B/L admitted with above mentioned complaints...." Due to which to rule out any non-disclosure of pre-existing disease vis-à-vis breach of the non-disclosure clause of terms & conditions of policy contract between complainant and opposite party No. 1, a query was raised with the insured/complainant to provide the FCP - first consultation treatment record of B/L. Osteoarthritis through query letters to the complainant and investigation was also conducted for the same. The customer stated through her reply in the claimant questionnaire that in March'2018 while walking her leg slipped and her knee bent and she took treatment from a massage clinic "madina clinic" of which she doesn't have any slip.The medical documents of current treatment states her condition to be of B/L(bilateral) osteoarthritis, which means her both knees have this condition of degenerative nature, which is exactly opposite of the answer she has mentioned about her leg slip and knee bent because Osteoarthritis doesn't happen from leg slip. The opposite party No. 1 has mentioned medical literature in this regard, the reproduction of which is not considered necessary at this stage.

13. It is pleaded that the alleged claim under the policy received from the complainant his wife was admitted in hospital and treated for chest pain under evaluation. While reviewing claim, opposite party No. 1 got to know that customer has history of hysterectomy (as per documents submitted by customer hysterectomy was done in 2009 for fibroid which has no impact on claim) and B/L osteoarthritis but duration was not mentioned. So opposite party raised query for duration. Investigation was also done. Customer is denying about any history of OA but there is a medical documents which shows history of OA. Moreover, there is doctor's certificate where doctor has mentioned that duration of OA is not known to him as it was mentioned by patient during taking history. Since the TDC received from the doctor of the hospital where insured currently took treatment, did not mention and date of diagnosis was not received because the doctor was not the one who treated for osteoarthritis, the same was not considered and the other requirement of first prescription of Osteoarthritis was not received after constant reminders the claim was rejected, citing the relevant section 3 (i) of the policy wordings, which requires necessary documents to be submitted for the claim to be processed.

14. It is pleaded that as per Section 3 (1) - "Claims Payment" that insurer shall be under no obligation to make any payment under policy unless the documentation and information have been provided to establish the circumstances of the claim, it quantum or liability for it. The opposite party No. 1 has also mentioned some policy conditions, the reproduction of which is not considered necesssary at this stage.

15. Further preliminary objections are that the complaint is not mantainable since the claim does not fall within the insurance as granted and there is no deficiency in services on part of opposite party. The opposite party No. 1 submitted complainant be directed to provide necessary medical documents of his wife condition of B/L Osteoarthritis, so that claim of the complainant can be processed as per terms and conditions, as these medical document are most significant if the customer's conditions is not sustaining since prior to policy inception, because then the condition of non-disclosure would be breached and the policy would be void ab initio, as per the terms and conditions of contract of insurance.

16. In additional submission, the opposite party No. 1 has submitted that the claims are paid by any Insurance Company out of the common pool of funds belonging to all policyholders of the Company which makes it obligatory upon the Insurance Company to check the genuineness and admissibility of each claim before honoring it in the larger interest of all the policy holders. The Insurance Company cannot do injustice to genuine policyholders by allowing inadmissible claims.

17. In parawise reply the opposite party No. 1 has pleaded that customer-never disclosed about insured's condition of B/L Osteoarthritis in the signed enrolment form & that the complainant after duly understanding and being satisfied with the features and the policy terms & conditions of the policy, had availed a Health Insurance Policy of the opposite party with sum assured of Rs. 5,00,000/- covering himself and spouse. The complainant can avail the benefits of the policy only as per terms and conditions of the policy. The opposite party provides its best services to its entire customers as per terms and conditions of the policy. After understanding all the terms and conditions of all the plans complainant opted to purchase Family Plan 2 (A) of the opposite party. For this, he filled the Proposal Form and at the time of filling the Proposal Form, he opted to pay requisite premium against the Sum Assured of Rs. 5,00,000/-. That soon thereafter the policy was dispatched to the complainant and the same was duly received by him. Before signing the Proposal Form, the complainant made declaration and signed the same.

18. It is further pleaded that after receiving the investigation report from the Investigatory, the opposite party No. 1 asked the complainant to provide first prescription medical documents related to B/L osteoarthritis and TDC explaining the cause of chest pain in revert of which the complainant provided a TDC of the doctor who attended her in the current hospitalization, but there is no mention about the first prescription of B/L Osteoarthritis. It was not sufficient rather the same was silent on the history of Osteoarthritis. The doctors have not even denied anywhere in the certificate that customer is not suffering from osteoarthritis. The rejection of the claim under the policy as per the provisions of insurance law as applicable with Indian Territory. A proper service has been provided by the replying opposite party to the complainant, so there is no deficiency in service on the part of the replying opposite party. After controverting all other averments, the opposite party No. 1 prayed for dismissal of complaint.

19. On the statement of learned counsel for the complainant, name of opposite party No. 2 was deleted from the array of the opposite parties.

20. In support of his complaint, the complainant has tendered into evidence his affidait dated 2-1-2019 (Ex. C-1), photocopy of Insurance Policy (Ex. C-2), photocopy of account statement (Ex. C-3), photocopy of lab report (Ex. C-4), photocopy of fee receipts (Ex. C-9 to Ex. C-19), photocopy of test report (Ex. C-20), photocopy of discharge summary (Ex. C-21), photocopy of bill (Ex. C-22), photocopy of test report (Ex. C-23), photocopy of bills (Ex. C-24 to Ex. C-27), photocpy of test reports (Ex. C-28 to Ex. C-30), photocopy of bills (Ex. C-31 to Ex. C-35), photocopy of e-mail (Ex. C-36), photocopy of treatment summary (Ex. C-37), photocopy of letter (Ex. C-38), photocopy of reminder letter (Ex. C-39), photocopy of rejection letter (Ex. C-40) and closed the evidence.

21. In order to rebut this evidence, the opposite party No. 1 has tendered into evidence photocopy of Enrollment Form (Ex. OP-1/1), photocopy of certificate (Ex. OP-1/2), photocopy of terms and conditions (Ex. OP-1/3), photocopy of Claim Form (Ex. OP-1/4), photocopy of claim verification report (Ex. OP-1/5), photocopy of rejection letter (Ex. OP-1/6), affidavit dated 26-2-2019 of Deepti Rostagi (Ex. OP-1/7), photocopy of power of attorney (Ex. OP-1/8) and closed the evidence.

22. We have heared learned counsel for the parties and gone through the record carefully.

23. These are undisputed facts between the parties that complainant and his wife were insured with opposite party No. 1 vide Insurance policy (Ex. C-2) No. 140100/12586/2018/A008253/ PE00808888 for the period from 16-1-2018 to 15-1-2019 under policy name 'Group Assurance Health Plan' 0022623 for sum of Rs.5,00,000/-. The wife of the complainant suffered from chest pain and she remained admitted in CMC, Ludhiana, for the period from 18-7-2018 to 20-7-2018 and therafter she also got follow-up treatment from said hospital. In total she spent Rs. 37,489/-. The complainant submitted claim with opposite party No. 1 for reimbursement which was rejected vide Rejection letter dated 17-10-2018 (Ex. OP-1/6).

24. The plea taken by the opposite party for rejecting the claim of the complainant is that the discharge summary of patient Surinder Kaur reveals that she was suffering from B/L Osteoarthritis. The opposite party asked the complainant to provide first prescription medical documents related to B/L Osteroarthritis & TDC explaining the cause of chest pain, in revert the complainant provided TDC of the doctor who attended her in the current hospitalization but the same did not mention about the first prescription of B/L Osteoarthritis. In this way, the complainant has breached the terms and conditions of the policy by not disclosing pre-existing disease.

25. The complainant has pleaded that in March, 2018 while walking Surinder Kaur slipped and her knee bent. She took massage treatment from local man, of which she does not have any slip.

26. As discussed above, there is no dispute regarding treatment taken by wife of complainant Surinder Kaur from CMC, Ludhiana, for Acute Coronary Syndrome – Unstable Angia from 18-7-2018 to 20-7-2018. B/L (bilateral) Osteoarthritis mentioned in the discharge summary has no link/relevancy with the disease for which treatment was taken and reimbursement of claim filed by complainant. However, if opposite party is of the view that complainant has concealed or not disclosed B/L Osteoarthiritis while taking policy and they donot believe the version of complainant that she never took any treatment for this problem, it is for the opposite party to prove their version by producing evidence that Surinder Kaur ever took any treatment from any hospital for B/L Osteoarthiritis and she was suffering from this disease before taking policy of the opposite party and she did not disclose this fact in proposal form. The only evidence relied upon by the opposite parties in this regard is the discharge summary of Surinder Kaur wherein she herself has disclosed this problem.

27. In the case of Virpal Nagar Vs. HDFC Standard life Insurance Co. Ltd., II (2019) CPJ 59 (Del.), Hon'ble Delhi State Commission after noticing the observations of Hon'ble National Commission and Hon'ble Supreme Court in various judgements, concluded that :-

    “Unless and until a person is hospitalised or undergoes operation for a particular disease in near proximity of obtaining insurance policy or any disease for which he has never been hospitalised or undergone operation is not a pre-existing disease.”

    It was also observed :-

    “Malaise of hypertension, diabetes, occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in or out of the house and are controllable on day-to-day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalised or operated upon for treatment of these disease or any other disease.”

28. The opposite party has not placed even a single document on file to prove that Surinder Kaur took any treatment for B/L Osteoarthiritis. It is for the opposite party either to prove their version or believe the version of the complainant but the opposite party without reason, rejected the claim of the complainant on flimsy grounds. Moreover, the opposite party is also failed to bring on record any document proving that disease for which complainant has taken treatment was due to B/L Osteoarthiritis.

29. Therefore, keeping in view the facts, circumstances and the evidence placed on file by the parties, this Commission is of the considered opinion that there is deficiency in service on the part of opposite party No. 1 in rejecting the genuine claim of complainant.

30. Resultantly, this complaint is partly allowed with Rs. 5500/- as cost and compensation. The opposite party No. 1 is directed to pay to complainant claim amount of Rs. 37,489/- with interest @ 9% w.e.f. 17-12-2018 (date of repudiation) till payment.

31. The compliance of this order be made within 45 days from the date of receipt of copy of this order.

32. The complaint could not be decided within the statutory period due to heavy pendency of cases.

33. Copy of order be sent to the parties concerned free of cost and file be consigned to the record.

    Announced :

    08-11-2021

    (Kanwar Sandeep Singh)

    President

     

     

    (Shivdev Singh)

    Member

     

    (Paramjeet Kaur)

    Member