State Consumer Disputes Redressal Commission
Parveen Vij vs M/S Apollo Munich Health Insurance Co. ... on 16 March, 2016
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, DAKSHIN MARG, SECTOR 37-A, CHANDIGARH.
First Appeal No.594 of 2015
Date of institution : 08.06.2015
Date of decision : 16.03.2016
Parveen Vij son of Shri Bharat Bhushan Vij, resident of H.No.B-
XXXIV-2605, Rajesh Nagar, Near Naseeb Enclave Haibowal Kalan,
Ludhiana.
(Alternate Address: House No.2605, New Tagore Nagar, Ludhiana).
.......Appellant-Complainant
Versus
1. M/s Apollo Munich Health Insurance Co. Ltd., SCO No.146, 2nd
Floor, Feroze Gandhi Market, Ludhiana through its Branch
Manager.
2. M/s Apollo Munich Health Insurance Co. Ltd., 10th Floor,
Building No.10, Tower-B, DLF City, Phase-2, Gurgaon
(Haryana)-122 002 through its Managing Director/General
Manager/Principal Officer.
......Respondents-Opposite Parties
First Appeal against the order dated
23.02.2015 of the District Consumer
Disputes Redressal Forum, Ludhiana.
Quorum:-
Hon'ble Mr. Justice Gurdev Singh, President.
Shri Vinod Kumar Gupta, Member.
Present:-
For the appellant : Shri Sandeep Khunger, Advocate. For the respondents: Shri Nitin Thatai, Advocate. JUSTICE GURDEV SINGH, PRESIDENT :
This appeal has been preferred by the appellant/complainant against the order dated 23.2.2015 passed by District Consumer First Appeal No.594 of 2015. 2 Disputes Redressal Forum, Ludhiana (in short, "District Forum"), vide which his complaint filed under Section 12 of the Consumer Protection Act, 1986, was partly allowed and the respondents/opposite parties were directed to re-examine his case qua the disease Gall Bladder Polyp as well as prescription of anti- inflammatory medicine and to allow his claim in case that treatment was in accordance with the terms and conditions of the Policy and also directed them to pay Rs.3,000/-, as compensation and litigation expenses.
2. The complainant alleged, in his complaint, that in the month of December 2010 representative of opposite party No.1 approached him and induced him to buy Health Insurance Policy by representing that the same would cover the risk of ailments and hospitalization. That Policy was taken by him on December 14, 2010 for himself and his family members after the payment of Rs.6,938.98P and the risk was covered upto 19.12.2011. Thereafter he had been getting that Policy renewed and lastly the same was renewed upto December 2015. He was feeling weakness, reduction in weight and restless sleep from the last one month and, as such, approached Fortis Hospital, Ludhiana. He was admitted in that Hospital on 24.5.2014 and at that time he signed the consent form. About his ailment he informed the officials of the opposite parties. He was medically examined and the doctors did other prognosis and gave proper treatment. After that treatment he was discharged on 28.5.2014. During his hospitalization he spent Rs.34,630/- on the medical tests and the medicines prescribed by the Doctors. He submitted claim of First Appeal No.594 of 2015. 3 that amount with the opposite parties supported by documents. His claim was repudiated, vide letter dated 26.6.2014, on the ground that the claim for Generalized Anxiety Disorder falls under Psychiatric/Mental/Genetic disorder and the treatment for the same is excluded in the Policy. That repudiation is illegal, void, capricious and unconstitutional. There is general tendency amongst the Insurance Companies to sell the Policies through their Agents/Representatives by giving allurements and assurances and then to repudiate the claims made under those Policies on one or false pretext and that act on the part of the Insurance Companies amounts to fraud and cheating. Once he was hospitalized and incurred expenses on medical treatment, the opposite parties were bound to settle his claim for reimbursement. Their act in repudiating his claim amounts to deficiency in service. He prayed for the issuance of following directions to them:-
i) to pay the claim amount of Rs.34,630/-;
ii) to pay Rs.50,000/-, as compensation, on account of
deficiency in service, which caused mental tension and uncalled harassment to him; and
iii) to pay interest at the rate of 12%.
3. The complaint was contested by the opposite parties/Insurance Company by filing written reply before the District Forum, in which it admitted that the Policy in question was obtained by the complainant from it after the payment of the premium; which was renewed from time to time and vide last renewal the risk was covered upto 19.12.2015. It also admitted that the claim submitted by the First Appeal No.594 of 2015. 4 complainant for reimbursement of the expenses under the Policy was repudiated on the ground mentioned in the complaint. While denying the other allegations made in the complaint, it averred that the complainant himself submitted the duly filled and signed proposal/application dated 13.12.2010 for the purchase of Easy Health Individual Standard Plan. The proposal made by him was accepted on Standard Rates basis on the information provided by him and the Policy was issued in his favour. Before acceptance of the proposal adequate information with regard to the product, nature and significance was given to the complainant and he was also provided the literature and necessary guidance. It's Financial Consultant/Agent duly explained to him all the terms and conditions in the language, which was best known to him and it was only after understanding those terms and conditions of the Policy that he put his signature on the declaration. The cashless request from Fortis Hospital, Ludhiana, was received by it on 24.5.2014 after the complainant was got admitted with the complaint of general weakness, weight loss and probable diagnosis of thyrotoxicosis with the estimated cost of Rs.38,500/- and estimated donation of stay of two days. On post reviewing the documents, additional information was raised on 24.5.2014, vide which the Hospital was asked to forward to it the investigation reports supporting the diagnosis with the treatment chart etc. No reply to that query was received and a reminder was issued on 25.5.2014 but again no reply was received. After the final reminder the Hospital sent the reply, which was insufficient and was not as per the query raised by it. Thereafter First Appeal No.594 of 2015. 5 another reminder was sent on 27.5.2014 and after the documents were received initial approval of Rs.20,000/- was given on 27.5.2014. On 28.5.2014 the medical documents were received from the Hospital for final approval and post reviewing. Those documents and particularly the progress note dated 24.5.2014 made it clear that the complainant was admitted in the Hospital only for the purpose of investigation and, as such, the cashless facility was rejected on 28.5.2014 on the ground that such a facility cannot be granted where a patient is admitted primarily for investigation and evaluation only. However, it was made clear that the complainant could file the claim for reimbursement after the completion of the treatment by supporting the same with all medical and financial records. After the claim was submitted by the complainant it was found that he was admitted in the Hospital only for investigation and evaluation of anxiety treatment; which was not covered under the Policy. Therefore, his claim was rejected. He has presented the allegations in the complaint in such a manner so as to present a distorted and twisted picture with an intention to misguide and confuse the District Forum and to get the favourable decision in his favour. He has not presented the true facts and has failed to provide the terms and conditions of the contract of insurance. The detailed reason for rejection of the claim was given in the repudiation letter. The complainant again made a request on 26.7.2014 stating therein that he was admitted for Gall Bladder Polyp but that was rejected, vide letter dated 28.10.2014 and the claim was not reopened. There was no such deficiency in service on its part nor it adopted any unfair First Appeal No.594 of 2015. 6 trade practice. It itself and the complainant are bound by the terms and conditions of the insurance policy and as per those terms and conditions, the complainant was not entitled to any such claim. He has no cause of action to file this complaint and the same is not maintainable. It prayed for the dismissal thereof with heavy costs; being an abuse of the process of law and having been filed with ulterior motive to harass and humiliate it.
4. Both the sides produced evidence in support of their respective averments before the District Forum, which after going through the same and hearing learned counsel on their behalf partly allowed the complaint, vide aforesaid order.
5. We have heard learned counsel for both the sides and have carefully gone through the records of the District Forum, which were called at the stage of admission of the appeal.
6. It has been submitted by the learned counsel for the complainant that it becomes very much clear from the Discharge Summary proved before the District Forum as Ex.R-13 that the complainant was hospitalized from 24.5.2014 to 28.5.2014 and during that period he was treated for Generalized Anxiety Disorder and Gall Bladder Polyp and during that hospitalization he incurred the expenses to the tune of Rs.34,630/-. Once that fact is proved, then by virtue of the terms and conditions of the Policy and which were proved on the record by both the sides, the opposite party was bound to reimburse that amount. As per those terms and conditions, Ex.R-4, the complainant was not only entitled to his treatment, as Indoor patient but also entitled to pre-hospitalization and post- First Appeal No.594 of 2015. 7 hospitalization expenses. If that is the case, then the opposite party could not have repudiated his claim on the ground that he was admitted in the Hospital only for investigation and evaluation purposes and had not undergone any treatment. When such is the case, the appeal is liable to be admitted to be heard on merits.
7. On the other hand, it has been submitted by the learned counsel for the opposite party that the terms and conditions of the Insurance Policy contains the General Exclusions and as per those General Exclusions, no claim was admissible in respect of the treatment of the Psychiatric Mental Disorders, general debility or exhaustion or sleep-apnoea. At the most from the Discharge Slip, it can be made out that the complainant was diagnosed as a case of Generalized Anxiety Disorder and Gall Bladder Polyp but it cannot be made from that Discharge Summary itself or other evidence produced by the complainant that he was given treatment for the said diseases. Merely because the complainant remained admitted in the Hospital for 4 days and incurred expenses for the investigation and evaluation of the diseases, he does not become entitled to the reimbursement of the expenses incurred by him on the same. By virtue of the terms and conditions of the Policy such expenses are specifically excluded. Thus, there is no ground for admitting the appeal to be heard on merits.
8. In order to appreciate the arguments advanced by the learned counsel for the parties, the Course in the Hospital, as incorporated in the Discharge Summary, is reproduced below:-
First Appeal No.594 of 2015. 8
"Patient was evaluated thoroughly for his complaints. His Complete Blood Counts, Liver Function tests, Renal function tests, Thyroid Function Tests, ECG and Chest X-ray were within normal limits. His USG whole abdomen was done which showed GB Polyp for which Gastrosurgery consult was taken. Patient was advised Laparoscopic Cholecystectomy. Patient refused surgery and is now being discharged."
A perusal thereof makes it very much clear that tests and investigations were conducted during the stay of the complainant in the Hospital from 24.5.2014 to 28.5.2014 and on the basis of those tests he was advised Laparoscopic Cholecystectomy but he refused to undergo the surgery. It becomes very much clear therefrom that he had not obtained any treatment as indoor patient. Even if it is to be concluded from this Discharge Summary that he was treated for Generalized Anxiety Disorder, even then he is not entitled to claim any expenses in respect thereof by virtue of General Exclusions incorporated in the terms and conditions of the insurance policy and the relevant exclusion sub-clause is reproduced below:-
"Psychiatric mental disorders (including mental health treatments), Parkinson and Alzheimer's disease, general debility or exhaustion ("run-down condition"), sleep apnoea."
It is also clear from the perusal of the General Exclusions that the complainant was not entitled to the reimbursement of the expenses incurred by him for investigations and evaluations and he was only First Appeal No.594 of 2015. 9 entitled to the expenses incurred by him on his treatment and in fact he had not undergone any such treatment by virtue of which he became entitled to the claim under the insurance policy. Thus, we do not find any ground to admit this appeal to be heard on merits and the same is hereby dismissed in limine.
9. The appeal could not be decided within the statutory period due to heavy pendency of court cases.
(JUSTICE GURDEV SINGH)
PRESIDENT
(VINOD KUMAR GUPTA)
March 16, 2016 MEMBER
Bansal