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Avneet Kaur
Jalandhar, December 29
On a complaint filed by Raj Kumar, a resident of Master Tara Singh Nagar, the District Consumer Disputes Redressal Forum, has penalised Apollo Munich Health Insurance Company Limited for refusing claim to the complainant.
The company was fined Rs 43,055. The complainant had obtained the ‘Health Insurance Mediclaim Optima Restore Floater Policy’ in 2015 and got it renewed from September 5, 2016, to September 4, 2017. Under the policy, the wife and the son of the complainant were also covered with a sum of Rs 3 lakh.
On January 23, 2017, Raj Kumar complained of palpitations (fast heartbeat) and was admitted to Care Max Super Speciality Hospital, Jalandhar, and discharged on January 25, 2017.
The matter was reported to the company and the complainant lodged a claim for Rs 33,055 for medical treatment. He presented prescribed claim forms, bills, receipts, discharge certificate, along with clinical test, to the insurance firm.
The complainant said despite having submitted the required documents and certificates issued by the doctor, the firm rejected the claim on the grounds that he was diagnosed with sleep apnea and underwent the treatment for the same, which was excluded from the insurance policy.
The complainant stated that he was admitted to the hospital for the treatment of palpitations and was diagnosed with sleep apnea later and he hold certificate and discharge papers issued by the hospital that says he was treated for palpitations not sleep apnea.
The firm in its reply to the forum averred that on February 1, 2017, a reimbursement claim was submitted on behalf of the complainant for the reimbursement of Rs 33,055. But as per their investigation from the hospital and from available documents, they found that the complainant was admitted for the management of diabetes mellitus, palpitations, sleep apnea and underwent sleep study and later, the patient was discharged.
The firm said after post-scrutiny of the documents, it was noticed that the patient was admitted with palpitations during hospitalisation but he had underwent treatment for sleep apnea. The claim was rightly rejected as the disease of sleep apnea was excluded from the health insurance policy taken by the complainant.
The order
The forum, in its reply, after verifying from the treating doctor, HS Dhingra, who admitted that the complainant was hospitalised at Care Max Super Speciality Hospital, Jalandhar, with palpitations and accordingly, he was treated for it.
It stated that it was cleared from the documents of the hospital that initially the complainant was admitted to the hospital for the treatment of palpitations and was not admitted for the treatment of sleep apnea.
The forum added that there was no intentional or wilful suppression of any fact by the complainant, prejudicial to the terms and conditions of the policy.
The forum, thus, ordered to the insurance firm to repay an amount of Rs 33,055, along with compensatory cost of Rs 7,000 and litigation cost of Rs 3,000, to the complainant.
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