Legal Question in Insurance Law in India

Dear Sir,

Please advice on the following case -

My previous employer (M/S LKS India Private Limited) have taken Optima Restore Family Floater policy number 6000037432 with inception date 27 Jun 2012 for sum insured of Rs.3 lacs for me and my two family members. I was Executive Director of LKS India Private Limited till 30th November 2013 and I only approved changing from Star Health Insurance to Apollo Munich for self and other employees of the company, hoping for a better service from Apollo Munich, if known that Apollo Munich behaves like this would not have come under the influence of Apollo Munich authorized agent Mr. Vishal Vitthal Otawanekar (80113600) who manipulated us to shift from Star Health Insurance to Apollo Munich assuring the better services (which in fact was also not as per the provisions of 5b of IRDA (Health Insurance) regulation 2013.

Mr. Vishal Vitthal Otawanekar, himself filled the application form and verified all the desired information to be filled in the form as may be needed by Apollo Munich and the same has been received by Apollo Munich on 20th June 2012 and accordingly put into inception wef. 27 Jun 2012. The same policy was renewed for the current year as well.

It also to be noted that for the self and other employees, I have also taken the personal Accident Insurance Coverage (Policy no. 200007231, dated 26th Jun 2012) for sum insured Rs.10 lacs from Apollo Munich through the same authorized agent Mr. Vishal Vitthal Otawanekar (80113600).

On 18th November 2013, I underwent Angioplasty for the Right Coronary Artery Blockage. I was discharged on 20th November 2013.

I registered the Medical Claim ref. ID 165762 (Apollo Munich) and received letter dated 10th January 2013 from Apollo Munich stating that my claim is rejected and policy is terminated due to non-disclosure of the Ischemic Heart Disease and Cardiomyopathy diagnosed 10 years back.

I refuted the letter and escalated to Grievance Cell of Apollo Munich by giving medically correct technical reasons and references of the definition of Pre-exiting condition waiting period as defined in the terms & wording of the policy and the same was acknowledged by Grievance cell on 14th Jan 2014 mentioning my IRDA token number is 01-14-014896. Mr. Narendra Singh Bhist (Assistant Manager) reverted on 17th Jan 2014 with the same stand of rejection of my health claim and termination of policy Optima Restore Family Floater policy number 6000037432.

I again written to Mr. Narendra Singh Bhist (Assistant Manager) giving him all justifications relevant to the pre-exiting condition and requesting Grievance cell to review under the policy terms but in vain he again reverted on 26th Dec 2013 with same stand.

I wrote the email to IRDA dated 26th January 2014 attaching the 2d-Echo and Angiography report of 10 years back (November 2003) which state Non-Obstructive Hypertrophic Cardiomyopathy with normalcy of the Heart Valve & Chambers, normal arteries with no Coronary artery disease, I got email reply dated 27th Jan 2014 from Mr. Narendra Singh Bhist with a changed stand and then saying that the member before policy inception has been diagnosed with;

1. Hypertrophic cardiomyopathy.

2. Rest angina without any blockage of coronary arteries (Angiography �ve, but stress test +ve).

Had these facts been made available to us at inception, the policy would not have been issued in the beginning. Moreover either of the conditions (only Hypertrophic cardiomyopathy without h/o IHD) would have been sufficient to reject the cover� however seems purposely missed to mention here 10 years back.

I again referred the case to Mr. Antony Jacob (CEO of Apollo Munich) and then Mr. Padmesh Nair (Grievance Officer) came in the picture and he reverted on 30.01.2014 saying that he is personally looking at my case and shall revert early next week. In case he need any information from my end, will get in touch with me. But he too didn�t ask of any justification and unilaterally reverted to the previous stand as mentioned in the letter dated 10th January 2014 and even ignoring his own colleague changed stand made on 26th January 2014 and sending me the scan copy of 1st and the last page only of the proposal form, reasons best known to him?.

This reveal that Padmesh Nair (Grievance Officer) too has not done any proper and fair investigation of the subject associated with the technicalities of the Cardiomyopathy, its no-relation with Coronary Artery Blockage and the policy terms and wording but prefer to defend the unfair rejection of the claim as was done by his previous colleague.

I wrote back to him sending me all the pages of the proposal form and then after reminder his college sent me the scan of all the four pages of the proposal form.

Now, I am helpless and forced to seek the justice from Insurance Ombudsman under Protection of the Policy Holders interest by highlighting various valid grounds and violation by Apollo Munich as under �

1. The proposal was filled by the Apollo Munich authorized Agent Mr. Vishal Vitthal Otawanekar (it can be verified by the handwriting expert) and he just took my signatures on the 1st and last page only saying formality is complete? Any material informations (details, requirements or consequences etc.) were seems purposely hidden/ not advised by Apollo Munich authorized Agent Mr. Vishal Vitthal Otawanekar, who himself submitted the proposal form to Apollo Munich.

As indicated above, the policy was shifted from Star Health Insurance to Apollo Munich therefore I should get the Portability benefits (if any), however the was also not mentioned in the proposal form filled by Apollo Munich authorized Agent Mr. Vishal Vitthal Otawanekar?

While issuing the policy, Apollo Munich too seems purposely not asked for any �material informations� (pre-medical check-up requirements or consequences etc.) towards may be required by them for commencing the policy wef. 27th June 2012 but unfairly trying to include in their letter of claim rejection now to take undue advantage.

Isn�t above is serious breach of Trust and violation of IRDA regulation (as defined under �Point of sale�) by Apollo Munich Authorised Agent, may be under advice of Apollo Munich to keep the customers in dark and least informed so that they can take advantage securing their interests. Insurance Ombudsman is requested to take stern action against such Agents and the companies they are associated with?

2. Apollo Munich issued policy terms on page 1 under waiting period stating � Pre-existing disease shall be covered after a waiting period of 36 months.

The Pre-existing condition is defined as per the Def. 26 given on page 6 of the policy - ��Pre-existing Condition: means any condition, ailment or injury or related condition(s) for which insured person had signs or symptoms and/or were diagnosed, an / or received medical advice / treatment within 36 months prior to the commencement of his first being covered under an Optima Restore Policy issued by us.�

Therefore termination of the policy and rejection of claim is violation of the IRDA circular to all CEO � IRDA / HLT / CIR / 036 / 02 / 2013 dated 20/02.2013 which clearly define the exclusions from the list of critical illness. The said circular and the list of exclusion of the policy also doesn�t include the Non-Obstructive Hypertrophic Cardiomyopathy with normal valves/chambers and no thrombus/vegetation/ pericardial effusion anywhere as critical/serious illness.

Therefore the rejection of claim and termination of the policy on the ground of 10 year old diagnosis of mild Hypertrophic cardiomyopathy (Non-Obstructive type having all normal heart valves and chambers ) and Rest angina without any blockage of coronary arteries (Angiography �ve, but stress test +ve).

3. From the policy wordings of waiting period and pre-existence conditions as mentioned under point 2 above, it gives understanding that the material fact as being referred by Apollo Munich pertains to the �pre-existing conditions� during the waiting period of 36 months only from the date of policy inception.

Since, there is no definition of material fact is given in the policy which may clearly state that the pre-existing condition even if diagnosed prior to waiting period of 36 months from the date policy inception comes under the definition of Material fact, therefore without spelling out the material informations clearly and later rejection of claim and termination of the policy on the ground of 10 year old diagnosis is absolutely unfair and unlawful.

4. The diagnosis of Non-Obstructive HCM was 10 years old and 2d-Echo and CAG reports clearly reveal the normalcy of heart valves/chambers and no existence of Coronary Artery Disease, even the latest 2d Echo dated also states the same with no significant change from the 10 year old report.

I have lived quite a disciplined and claim less life and have no other complications like Hypertension, BP or Diabetes which may have nexus with Coronary Artery Disease and I have lived Healthy/normal claimless life before and after above mild HCM detection.

Further, HCM is a permanent condition of the heart caused with unknown reasons and generally don�t affect person and has no-relevance with the present ailment and doesn�t cause/result Coronary Artery Disease � which even can be checked/verified from qualified Cardiologist and medical literature/books but Apollo Munich never felt necessary to look into this technical aspect.

As other reputed institute, The National Heart Lung and Blood Institute (NHLBI) define Hypertrophic cardiomyopathy (HCM) as under �

Some people who have HCM have no signs or symptoms. The disease doesn't affect their lives� - http://www.nhlbi.nih.gov/health/health-topics/topics/cm/

Medeicine net states: Many people with HCM have no symptoms or only minor symptoms, and live a normal life.

http://www.medicinenet.com/cardiomyopathy_hypertrophic/article.htm

Clevelandclinic also state: Many people with HCM live a normal life and do not experience health-related problems.

http://my.clevelandclinic.org/heart/disorders/hcm/default.aspx

The Wikipedia also state : Asymptomatic patients : A significant number of patients with hypertrophic cardiomyopathy do not have any symptoms and will have normal life expectancies�.

http://en.wikipedia.org/wiki/Hypertrophic_cardiomyopathy

I too had/have no signs or symptoms after diagnosis of Non-Obstructive Hypertrophic Cardiomyopathy 10 years ago and never ever felt shortness of breath, arrhythmias, or inability to exercise � If Insurance Ombudsman or honourable court ask I am ready for any Fatigue Test or running with Mr. Antony Jacob (CEO of Apollo Munich) to ascertain who�s heart is more normal and stronger.

My cardiologists, Dr. Shivram Bonagiri and Patki Dr. Nitin Patki are also ready to furnish the technical facts with the relevant authorities (if asked) and the same was never felt necessary by Apollo Munich while unilaterally rejecting my claim.

5. Coronary Artery Disease was 1st detected on 15th Nov. 2013 during Angio Scan and CAG on 18th Nov. 2013 and angioplasty was done same day. Thus It is clear that Coronary Artery Blockage was not a pre-existing disease.

Under the above facts, I wish to state that

1. I was/am honest in my disclosures and Insurance Ombudsman can understand that if I would have knowingly hidden the disclosure of my 10 years back HCM detection, I could have not submitted the discharge card with past history and tiered manipulating it but it was never the case and I have never tried manipulating any document, which proves my honest intentions in the good trust with Apollo Munich but left cheated by Apollo Munich.

2. the unfair stand by Apollo Munich that policy would have not been issued by the Apollo Munich amounts to the violation of IRDA guidelines, when claim was raised after paying handsome premiums, since the symptoms and diagnosis of Non-Obstructive Cardiomyopathy 10 years back doesn�t not fall in the category of the Critical illness and even if it would have been mentioned at the time of proposal stage they would could have not reject the cover it being under Group and cover is being taken by employer for its employees and if rejected the all the covers would have been withdrawn by the company at the proposal stage itself and this was known to the Apollo Munich authorised agent and Apollo Munich.

3. my claim is absolutely genuine and payable by Apollo Munich on technically justified grounds and Protection of Policy Holder Interest act.

However, Apollo Munich is intentionally rejecting the claim on the basis of unfair grounds in accordance to their now apparent unethical and bad business practices and causing me severe mental agony. I have raised the request up to the topmost management level of Apollo Munich but in vain.

I have requested �Insurance Ombudsman� to kindly intervene and do the justice with me under the provisions of �Protection of Policy Holder Interest� by advising Apollo Munich to settle my claim without any delay.

Thanks and regards,

Sandeep Jain

Eamil: [email protected]

Mobile: 8975758358

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