Here is why Apollo Munich asked to pay Rs 5.5L to Saidabad patient

Hyderabad: Consumer Dispute Redressal Commission has ordered Apollo Munich Health (now HDFC Ergo) to reimburse policy amount of Rs five lakh and pay Rs 50,000 compensation for denying health insurance benefit to a customer.

Complainant Lakshmi Mantha of Saidabad had taken Apollo Munich Health Insurance policy for a sum assured of Rs.2 lakh. Later the sum assured was enhanced to Rs 5 lakh for 2016-2017.

The complainant underwent heart surgery in Yashoda hospital, Malakpet in October 2017 and spent Rs.6.65 lakh for treatment and other charges. "I submitted a claim for Rs.5 lakh with the insurance company. The insurance company repudiated the claim on the ground of suppression of information regarding her treatment in 2004," said the complainant.

The insurance company said that they cannot settle the claims when the material facts were suppressed at the time of obtaining the policy. "The policy was issued subject to the terms and conditions and limitations thereof. As the claim of the complainant was not within the ambit of terms and conditions of the policy the same was rejected," said the insurance company.

In March 2018, the insurance company rejected the claim of the complainant on the ground of non-revealing the history of old Ischemic stroke occurred in 2004.

The complainant clarified the objections raised by the insurance company on several dates. But the opposite party without considering the same rejected the claim"I have taken treatment for C.V.A (Cerebro Vascular Accident) Ischemic stroke in the year 2004, when I received a small head injury due to a fall in the house. As seen from the record, I continued treatment up to 2009 as an outpatient and stopped using medicines as per the advice of the Neuro Physicians," said the complainant.

After observing all the documents and evidence, the commission observed that the complainant never was admitted to any hospital as inpatient for any disease and as such the contentions raised by the opposite party in the rejection letter are not tenable.

"Moreover, the complainant underwent heart surgery in October 2017 in Yashoda Hospital, Hyderabad and claimed the treatment expenditure incurred. The present ailment and the alleged suppression of old ailment are not one and the same. As such the rejection of the claim made by the complainant amounts to unfair practice coupled with a deficiency of services on the part of the opposite party," said the commission.

The commission asked the insurance company to pay the policy amount of Rs.5 lakh to the complainant together with an interest of 9 percent. The company was also asked to pay Rs 50,000 towards compensation to the complainant for causing inconvenience and mental agony. Besides, the commission asked the company to pay Rs.5,000 towards costs of litigation.