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 medchandru021y 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;
Hypertrophic cardiomyopathy.
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 needs 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?.
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?
During Pre-medical test also, I had given informations quite honetsly, even the history of my father(died due to hearth problem), casual smoking / alchohal by self(but Apollo Munich dinot felt it necessary to seek more material facts/informations from me). You will also note that the report is absolutely normal along with the ECG. Some more observation are worth mentioning here that :
The policy number mentioned in the report is 6100213225 while my policy number is 6000037432?
The medical was done on 27th June 12 the same is the date of policy inception, while the reports received by Apollo Munich was on 29th June 2012?
All the pages of the report do not have my signatures?
Apollo Munich issued policy terms on page 1 under waiting period stating – 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.
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 in