BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, KAITHAL.
Complaint Case No.296 of 2018.
Date of institution: 12.11.2018.
Date of decision:26.08.2019.
Arjun Garg age about 21 years, S/o Jai Bhagwan, R/o House No.557/7, Lal Peo, Ward No.8, Bagriyan Mohalla, Kaithal, Tehsil and District Kaithal (Haryana).
…Complainant.
Versus
- Tarun Khanduja office at Pinnacle Financial Services, Ist floor, near Honda Agency, Opp. Kaithal Club, Ambala Road, Kaithal.
- Apollo Munich Health Insurance Co. Ltd., 2nd and 3rd Floor, iLABS Centre, Plot No.404-405, Udyog Vihar, Phase-III, Gurugram-122016 (Haryana).
….Respondents.
Before: Sh. D.N.Arora, President.
Sh. Rajbir Singh, Member.
Smt. Suman Rana, Member.
Present: Sh. Arun Kumar, Advocate, for the complainant.
Op No.1 exparte.
Sh. Naresh Sharma, Advocate for the OP.No.2.
ORDER
D.N.ARORA, PRESIDENT
The complainant has filed the present complaint under Section 12 of Consumer Protection Act, 1986, with the averments that the complainant purchased a health insurance policy from the Op No.2 for availing cashless facilities upto Rs.10,00,000/- alongwith other benefits and the first policy inception date was 04.07.2016. It is alleged that the complainant got renewed the said policy from 10.07.2017 to 09.07.2018 and thereafter from 10.07.2018 to 09.07.2019 vides policy No.110300/11119/AA00437720-02. It is further alleged that the complainant was suffering from spinal problem and pain lower abdomen belt lie sensation with pain reaching both lower limbs and he was also suffering from loss of sensation both lower limbs below knee joint and also suffering from pain in testicles all the time. The complainant was also suffering from the problem relating to urine. The complainant got himself medically checked-up in Indraprastha Apollo Hospital, New Delhi and the doctors advised the complainant to undergo operation and other treatment. The hospital authorities also gave an estimate to the tune of Rs.7,82,233.33 paise to be spent on the treatment of the complainant. The complainant told the hospital authorities that he is also having health insurance policy holder and the papers regarding the policy were submitted by the complainant to the hospital authorities for taking up the matter with the Ops for providing cashless service facility for treatment of the complainant. The Op No.2 vide letter dt. 08.08.2018 addressed to the Indraprastha Apollo Hospital, New Delhi denied to provide the cashless facilities under the said insurance policy on the false and baseless ground that the required documents were not provided by the complainant. However, the complainant had submitted all the documents to the Ops as required by them. So, it is a clear cut case of deficiency in service on the part of Ops and prayed for acceptance of complaint. Hence, this complaint.
2. Upon notice, the OP No.2 appeared before this Forum, whereas Op No.1 did not appear and opted to proceed against exparte vide order dt. 21.12.2018. Op No.2 contested the complaint by filing reply raising preliminary objections with regard to locus-standi; maintainability; cause of action; that the present complaint is time-barred; that the policy kit containing all relevant documents were duly received by the proposer , thereby giving an opportunity to insured to verify and examine the benefits, terms and conditions of the policy taken by the insured; that the proposer never approached to the answering Op company that any information given in the documents, in the policy kit was incorrect or any terms and condition therein is not understandable or acceptable to him within the free look period i.e. 15 days from the receipt of policy document; that on 08.08.2018 pre-authorization request was received from the hospital for the complainant who got admitted in the hospital and estimated cost of Rs.7,82,233/- was made; that post reviewing the documents so submitted by the hospital authorities, it was found that the complainant was known case of cyanotic heart disease at the age of one month and accordingly, query was raised and after repeated reminder no revert was received so cashless request was rejected stating that “Cashless facility cannot be granted as the required information/documents have not been provided by the provider/insured to decide admissibility. However, insured can file the claim for reimbursement post completion of the treatment with all medical & financial records. The admissibility of the claim would be decided post review of the documents and policy conditions. Provide discharge summary of surgery done at age 1 month, if not available provide Treating doctors certificate regarding Details of exact diagnosis and surgery done. Exact duration of Present ailment first consultation paper, all previous treatment records pertaining to the same”; that there is no deficiency in service on the part of Op. On merits, the objections raised in the preliminary objections are reiterated and so, prayed for dismissal of complaint.
3. The complainant tendered into evidence affidavit Ex.CW1/A and documents Ex.C1 to Ex.C14 and thereafter, closed the evidence.
4. On the other hand, the Op No.2 tendered into evidence affidavit Ex.RW2/A and documents Annexure-R1 to Annexure-R38 and thereafter, closed the evidence.
5. We have heard the learned Counsel for both the parties and perused the record carefully.
6. It is admitted fact that the complainant had purchased a health insurance policy from the Op No.2 for availing cashless facilities upto Rs.10,00,000/- alongwith the other benefits under accident and health insurance services as mentioned in the schedule of the policy. The first inception date of policy was on 04.07.2016. The complainant also got renewed the policy from 10.07.2017 to 09.07.2018 for availing the cashless facility. It is also not disputed that the complainant again got renewed the above-said policy third time for the period valid w.e.f. 10.07.2018 to 09.07.2019 to avail the cashless facility. The complainant alleges that he was suffering from spinal problem and pain lower abdomen belt lie sensation with pain reaching both lower limbs and he was also suffering from loss of sensation both lower limbs below knee joint and also suffering from pain in testicles all the time. The complainant was also suffering from the problem relating to urine. The complainant got himself medically checked-up in Indraprastha Apollo Hospital, New Delhi and the doctors advised the complainant to undergo operation and other treatment. They have given the estimate amounting to Rs.7,82,233.33 paise as per Annexure C2. The treatment record is Annexure C3 to Annexure C5 but the Op No.2 vide letter dt. 08.08.2018 denied to provide the cashless facilities on the ground as per Annexure R-15 dt. 12.09.2018 mentioned as under:-
“Cashless facility cannot be granted as the required information/documents have not been provided by the provider/insured to decide admissibility. However, insured can file the claim for reimbursement post completion of the treatment with all medical & financial records. The admissibility of the claim would be decided post review of the documents and policy conditions. Provide discharge summary of surgery done at age of 1 month, if not available provide Treating doctors certificate regarding Details of exact diagnosis and surgery done. Exact duration of Present ailment first consultation paper, all previous treatment records pertaining to the same.”
Now we have to decide this case on the ground that whether the complainant has concealed the facts regarding he had undergone surgery cynotic heart disease when he was 1 month old. We have minutely gone through the proposal form Annexure-R1. It is clearly mentioned in column 3 EXISTING/PREVIOUS INSURANCE DETAIL Sub Section 3 Section C at Sr.No.III as under:-
“Section C: Have any of the person proposed to be insured:
III. Question: Undertaken any surgery of been advised surgery in the last 10 years or have a surgery still pending?
Ans.: No.”
7. We have also gone through the previous record produced by the Ops Annexure R11. The complainant was operated cynotic heart disease when he was 1 month old. The policy has been taken by the complainant in the year 2016 and at that time, he was age of 21 years as per the proposal form Annexure-R1. As per proposal form, the surgery has not been undertaken in the last 10 years and he has given the answer “No”. Hence, the question of concealment of previous disease does not effect on giving of the cashless facilities to the complainant. So, the Op No.2 has wrongly denied the cashless facilities to the complainant on the ground that the complainant was got operated when he was age of 1 month. Even otherwise, as per Annexure-C4 the opinion given by Apollo Heart Institute on 11.09.2018 as under:-
“Cardiac surgery was done when he was 1 month old. Echo heart is normal. There is no relation of spinal problem with surgery done when he was 1 month old.”
The hospital authorities have advised the complainant to go the surgery. The complainant was presently suffering from spinal problem as mentioned in para No.6 of said order. The above-said surgery was required by the complainant immediately, therefore, the repudiation letter dt. 12.09.2019 Annexure R-15 is hereby quashed. In view of above discussion, we are of the considered view that the Op No.2 has wrongly denied the cashless service facilities under the health insurance policy for his treatment of spinal problem and pain lower abdomen and suffering from loss of sensation both lower limbs knee joint and pain in testicles all the time.
At the time of arguments, it has come to our notice that the policy in question which was renewed for the period w.e.f. 10.07.2018 to 09.07.2019 is expired. Ld. counsel for the complainant placed on record copy of the policy which was renewed from the period 05.08.2019 to 04.08.2020 known as Optima Restore Insurance Policy. It means the policy in question is continue one upto 04.08.2020. Hence, the complainant is entitled for the relief.
8. Thus, as a sequel of above discussion, we allow the complaint and direct the Op No.2 to provide cashless service facilities under the health insurance policy for his treatment mentioned above with immediate effect and the Op No.2 is also directed to pay Rs.20,000/- as lump sum compensation on account of harassment, mental agony including the litigation charges. Let the order be complied with within 30 days from the date of preparation of copy of this order, failing which, the complainant shall be entitled interest on the awarded compensation @ 9% p.a. for the defaulted period. A copy of said order be supplied to the parties free of costs. File be consigned to record-room after due compliance.
Announced in open court:
Dt.:26.08.2019.
(D.N.Arora)
President.
(Suman Rana), (Rajbir Singh)
Member Member.
