Delhi

North East

CC/123/2017

SH. RAKESH VARSHNEY - Complainant(s)

Versus

M/S APPOLLO MUNICH HEALTH INSURANCE CO.LTD. - Opp.Party(s)

23 Nov 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

Complaint Case No. 123/17

 

 

 

 

In the matter of:

 

		Sh. Rakesh Varshney S/o Sh. Vijay Pal Varshney R/o 30 B, J & K Pocket, Dilshad Garden, Delhi-110095		Complainant
		Versus
		M/s Apollo Munich Health Insurance Co. Ltd. Claim Department, Through its Manager, Office Address:- Noida Sales Offices, 3rd Floor, N 23, Sector 18, Noida U.P   Corporate Office:- Ist Floor, SCF 19, Sector 14, Gurgaon,Haryana-122001   Registered Office:- Apollo Hospitals Complex, Jubilee Hills, Hyderabad-500033 Andhra Pradesh		Opposite Party
			DATE OF INSTITUTION:         JUDGMENT RESERVED ON:                           DATE OF ORDER:		11.04.17 19.09.23 23.11.23

 

CORAM:

Surinder Kumar Sharma, President

Anil Kumar Bamba, Member

Adarsh Nain, Member

ORDER

Ms. Adarsh Nain, Member

The Complainant filed the present complaint under Section 12 of the Consumer protection Act, 1986 against the Opposite Party.

Case of the Complainant

1. The case of the Complainant as revealed from the record is that the Complainant bought mediclaim policy from Opposite Party for himself and his family members vide current policy No. 110102/11121/AA00073545 which was valid from 09.04.14 to 08.04.15 and the Complainant had paid Rs. 19,271/- as premium. The Complainant stated that on 30.12.15 wife of Complainant fell ill and remained admitted in Family Health Care Hospital till 04.01.16 and underwent stomach surgery. It is further stated that the doctor of said hospital i.e. Family Health Care Hospital mentioned in the medical certificate that the wife of the Complainant is suffering from uncontrolled D.M for last 4 years. However, later on, Dr. Shivolok Narayan recognized the DM of the wife of the Complainant and came to the conclusion that she is suffering from D.M. for last only 1 year. It is submitted that no document shows that the wife of the Complainant suffers from any diseases only she was not aware anything about the said disease. The Complainant had incurred Rs. 94,632/- for the surgery and his wife‘s treatment and the bill was cleared by the complainant to the hospital on 04.01.16. Thereafter, Complainant filed up the claim with Opposite Party and requested Opposite Party to pay its liability but Opposite Party intentionally and deliberately refused the claim of Complainant. On 31.12.15 Opposite Party sent letter to Complainant mentioning that cashless facility cannot be granted as need of hospitalization is not established based on the available documents. The admissibility of the claim would be decided post review of the documents and policy condition. Thereafter, on 23.01.16 Complainant has sent all the relevant documents to the reimbursement by speed post but no reply has been given. Hence, this shows deficiency in service on behalf of Opposite Party. The Complainant has prayed to pay Rs. 94,632/- as actual expenses incurred on the treatment of his wife and borne by him along with interest @ 24 % p.a. till the realization of said amount. He further prayed for Rs. 1,00,000/- for mental harassment and Rs. 20,000/- towards litigation expenses.

Case of the Opposite Party

2. The Opposite Party entered the appearance and filed their reply. The Opposite Party while admitting  to have issued the policy, contends that the discharge summary dated 04.01.2015  issued by the treating hospital clearly states that complainant was a diagnosed case of Diabetes Mellitus T2 and of hypothyroidism and was under medication for these ailments but the complainant did not disclose this fact at the time of taking the policy. It is submitted that the claim of the complainant was rightly repudiated due to said non-disclosure of the material facts at the time of taking the policy. Since the complainant suppressed material facts as regards to the health conditions of his wife, the Opposite Party repudiated the claim under the terms of the policy, hence, the complainant being baseless deserves to be dismissed.

Rejoinder to the written statement of Opposite Party

3. The Complainant filed rejoinder to the written statement of Opposite Party wherein the Complainant has denied the pleas raised by the Opposite Party and has reiterated the assertions made in the complaint.

Evidence of the Complainant

4. The Complainant in support of his complaint filed his evidence by way of affidavit wherein he had supported the averments made in the complaint.

Evidence of the Opposite Party

5. In order to prove its case Opposite Party has filed affidavit of Ms. Deepti Rustagi, Constituted Attorney of Opposite Party, wherein the averments made in the written statement of Opposite Party have been supported.

Arguments & Conclusion

6. We have heard the parties and perused the file and the written arguments filed by the parties.
7. The case of the complainant is that the Complainant and his family were insured with the Opposite Party company under the subject mediclaim policy. It is submitted that during the effective policy, his wife underwent stomach surgery in Family Health Care Hospital and incurred Rs. 94,632/-. The grievance of the Complainant is that the Opposite Party had repudiated his claim on the ground of non-disclosure of material fact that his wife was suffering from uncontrolled Diabetes mellitus for last 4 years. The contention of the Complainant is that there is no document to show that Complainant was suffering with uncontrolled Diabetes mellitus. The Opposite Party had not paid the valid claim of the Complainant and committed deficiency in services.
8. On the other hand, the contention of the Opposite Party is that the discharge summary dated 04.01.2015 issued by the treating hospital clearly states that Complainant was a diagnosed case of Diabities Mellitis T2 and of hypothyroidism and was under medication for these ailments but the Complainant did not disclose this fact at the time of taking the policy. Since the Complainant suppressed material facts as regards to the health conditions of his wife, the Opposite Party repudiated the claim under the terms of the policy, hence, the complaint, being baseless, deserves to be dismissed.
9. Perusal of record shows that there is not dispute as regards the policy issued by the Opposite Party. The contention of the Complainant is that Opposite Party has wrongly repudiated his claim on the ground of non-disclosure of pre-existing disease. While the Opposite Party has contended that during verification of the claim, it was observed that the Complainant’s wife was suffering from uncontrolled Diabetes mellitus at the time of taking policy in question and the Complainant was aware of the of the medical condition. It is also contention of the Opposite Party that there was discrepancy in the medical record regarding the period of past history of uncontrolled Diabetes mellitus and the Complainant did not clarify that in spite of several requests made. The Opposite Party has based their case on first consultation paper of the patient which mentions that the Complainant’s wife was suffering with uncontrolled Diabetes mellitus since past 4 years and was on regular medication.
10. The perusal of the record reveals that the Complainant has stated in the complaint itself that the first consultation paper wrongly mentioned the period of past history and has produced the duly signed letter of the treating doctor Shivlok Narayan mentioning that at the time of admission, wrong history was taken by mistake and the patient was suffering from uncontrolled Diabetes mellitus since past 1 year only. The Complainant has also supported his case by filing another Doctor’s OPD prescription of patient dated 07.04.2015, issued by Ayush Diagnostic and health care centre. The said letter mentions that there was no history of diabetes. It is observed that the Opposite Party has neither rebutted/ challenged the above noted letters nor produced any evidence in support of their case.
11. Moreover, the discharge summary of the Complainant’s wife only mentions the disease and nowhere mentions the time period of past history of disease and surprisingly, the Opposite Party is taking support of the said document in their defence.
12. Since, the Opposite Party has failed to produce any document in support of their contention that Complainant’s wife was suffering with uncontrolled Diabetes mellitus since past 4 years and same was not disclosed, the contention cannot be accepted. The Opposite Party has failed to prove that the Complainant was suffering from the uncontrolled Diabetes mellitus and did not disclose at the time of taking the policy. Hence, the repudiation of the Complainant’s claim on the ground of non-disclosure of material fact of pre-existing disease was unjustified. In such case, the Complainant was entitled to the claim filed under the valid policy and the Opposite Party committed deficiency in not paying a genuine claim.
13. In view of above discussion, we are of the considered view that the Opposite Party has committed deficiency in services by repudiating a genuine claim under a valid policy.
14. Thus, the present complaint is allowed and the Opposite Party is directed to pay the claim amount of Rs. 94,632/- along with interest @ 9 % p.a. from the date of institution of the complaint till recovery. The Opposite Party is also directed to pay Rs. 25,000/- towards compensation and Rs.10,000/- towards litigation cost along with interest @ 9 % p.a. from the date of this order till its recovery.

Copy of this order be given to the parties free of cost.

File be consigned to Record Room.

(Anil Kumar Bamba)           Member

(Adarsh Nain) Member

(Surinder Kumar Sharma) President