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SHANTANU S. KEMKAR, S. S. BANSAL, MONIKA MALIK
Sanjay Sahoo – Appellant
Versus
Apollo Munich Health Insurance Co. Ltd. – Respondent
ORDER
Dr. (Mrs) Monika Malik, Member—This appeal by the complainant/appellant is directed against the order dated 22.04.2019 passed by the District Consumer Disputes Redressal Commission, Indore-2 (for short ‘District Commission’) in C.C.No.426/2017, whereby the complaint filed by the complainant/appellant has been dismissed.
2. Undisputed facts of the case are that the complainant/appellant had obtained a health insurance policy no. 170500/11002/1000297605 from the opposite party-insurance company first time, for the period w.e.f. 15.05.2012 to 14.05.2013. The sum insured under the said policy was Rs.3,00,000/- This policy was renewed every year and was in continuation uptill 14.05.2017.
3. The complainant had approached the District Commission stating that he had suffered cardiac ailment on 18.11.2013 and was hospitalized at CHL Hospitals, Indore. He was discharged on 20.11.2013. On claiming ‘critical illness’ sum insured, the opposite party-insurance company rejected his claim stating that ‘critical illness benefit’ is not payable as per policy terms and conditions. It is alleged that later, after 3 years, complainant suffered severe heart attack and was admitted in the same hos
IMPPORTANT POINTPolicy Schedule – It is preposterous that the insurance company is not able to decipher the terms, conditions & definitions, which are instanced in its own policy schedule. It is irra....
(1) Health Insurance Policy [Mediclaim Policy] – Repudiation based on exclusion clause which was not communicated to insured can never be pressed into service to deprive insured from claiming relief.....
Life Insurance Policy – Repudiation of death claim on the ground of suppression of material facts – Mere existence of past medical records is insufficient unless knowledge on part of insured is prove....
Mediclaim cannot be denied only on technical ground.
Medical Examination – Insurance company is responsible for conducting a medical examination of the policyholder in advance.
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