Haryana

Sonipat

317/2014

RAM CHANDER DAHIYA S/O DEEP CHADN - Complainant(s)

Versus

1. THE NATIONAL INSURANCE CO. LTD.,2. THE NATIONAL INSURANCE CO. LTD. - Opp.Party(s)

R.D.GAUR

07 Jan 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

SONEPAT.

               

 

                                Complaint No.317 of 2014

                                Instituted on:21.11.2014

                                Date of order:08.06.2015

 

Ram Chander Dahiya son of Deep Chand, resident of Shashtri Colony, Gohana road, Sonepat at present H.No.1402, Sector 23, Sonepat.

 

…Complainant.         

Versus

 

1.National Insurance Co. Ltd.  3, Middleton Street, Post Box No.9229, Kolkata-71 through its Chief Officer.

2.The National Insurance Co. Ltd. through its Branch Manager, Sonepat Branch Geeta Bhawan road, Sonepat now at Ist Floor Opp. Gurdwara Sahib, Old DC Road, Sonepat.

                                                     …Respondents.

 

 

COMPLAINT UNDER SECTION 12 OF

THE CONSUMER PROTECTION ACT,1986

 

Argued by: Sh. RD Gaur, Advocate for complainant.

           Sh. HC Jain, Adv. for respondents.

 

Before-    Nagender Singh-President.

Prabha Wati-Member.

DV Rathi-Member.

 

O R D E R

 

          Complainant has filed the present complaint against the respondents alleging therein that he purchased a mediclaim policy from respondent no.1 for the period w.e.f. 28.5.2014 to 27.5.2015 for a sum of Rs.4 lacs with Medsave Healthcare (TPA) Chandigarh.  Unfortunately on 12.8.2014, the complainant fell ill seriously and was got hospitalized in Medanta the Medicity Global Health Pvt. Ltd, Gurgaon.  The respondent no.1 was requested to pay the cashless facility , but of no us.  However, it was informed that the insured may submit necessary papers for reimbursement.  The complainant remained admitted for the period 12.8.2014 to 8.9.2014 in the said hospital. A total bill of Rs.10,40,302/- was raised by the hospital for treatment of the complainant.  On 14.10.2014 the complainant moved an application for settlement of the claim to the respondent no.2, but of no use and that amounts to a grave deficiency in service on the part of the respondents. So, he has come to this Forum and has filed the present complaint.

2.        In reply, the respondents have submitted that the policy does not cover the expenses incurred on account of the alleged treatment of the complainant.  The complainant prior to the issuance of the insurance policy had submitted proposal form wherein he had declared that he was not having any existing disease, illness and had not received any treatment for the last 3 years and on the basis of this declaration, the medi claim insurance policy was issued to the complainant w.e.f. 28.5.2014 to 27.5.2015.  As per medical report dated 14.8p.2014 issued by Medanta Hospital, Gurgaon, the3 complainant had history of diabetes mellitus for 7-8 years and there was history of CAD for the last 3 years and the complainant had underwent PTCA.  As per family history of hypertension was for 3 years and he was admitted for intracerebral hemrage and the pre-existing disease diabetes mellitus and hyper tensioin are the main cause of the present disease.  As per details supplied by the complainant to Medsave Healthcare TPA Ltd., the complainant had not received any treatment prior to his admission in Medanta Hospital, Gurgoan.  The complainant in this way has concealed the above mentioned facts regarding pre-existing disease and thus, the expenses incurred on the treatment of the present disease is not covered under the terms and conditions of the insurance policy and thus, it cannot be said that there is any kind of deficiency in service on the part of the respondents and thus, prayed for the dismissal of the present complaint.

3.        We have heard the arguments advanced by the learned counsel for both the parties at length.  All the documents have been perused very carefully and minutely.

          Ld. counsel for the complainant has submitted that the complainant has purchased a mediclaim policy from respondent no.1 for the period w.e.f. 28.5.2014 to 27.5.2015 for a sum of Rs.4 lacs with Medsave Healthcare (TPA) Chandigarh.  Unfortunately on 12.8.2014, the complainant fell ill seriously and was got hospitalized in Medanta the Medicity Global Health Pvt. Ltd, Gurgaon.  The respondent no.1 was requested to pay the cashless facility,  but of no us.  However, it was informed that the insured may submit necessary papers for reimbursement.  The complainant remained admitted for the period 12.8.2014 to 8.9.2014 in the said hospital. A total bill of Rs.10,40,302/- was raised by the hospital for treatment of the complainant.  On 14.10.2014 the complainant moved an application for settlement of the claim to the respondent no.2, but of no use.  It is further submitted that there is deficiency in service on the part of the respondents as they did not provide cashless facility to the complainant in case of his hospitalization and further did not settle the claim in favour of the complainant.

          In support of his contentions, he has relied upon the case law titled as Hari Om Aggarwal Vs. Oriental Ins. Co. Ltd. AIR 2008 Delhi 29  wherein it has been held that Presumption arises that exclusion clause would not cover such unforeseen ailments-Refusal by insurer to process and reimburse petitioner’s claim for expenses incurred for treatment of cardiac disease, on grounds that he had pre-existent condition that was specifically excluded, is arbitrary and unreasonable.

          Further in case titled as Usha Jhunjhunwala Vs.Oriental Ins. Co. Ltd. AIR 2013 Patna 113 it has been held that Repudiation of claim-Validity-Et-Armd/AMD with mixed CNVM was to inject anti-VEGF durg-It did not fall into category of treatment and therefore, was clearly not surgery-Not falling under exclusion clause-Repudiation of claim, not proper.

          He has also relied upon the case law titled as Smt. Tarannum Khatoon Vs. LIC of India, AIR 2011 Allahabad 182.

          On the other hand, ld. Counsel for the respondents have submitted that  the policy does not cover the expenses incurred on account of the alleged treatment of the complainant.  The complainant prior to the issuance of the insurance policy had submitted proposal form wherein he had declared that he was not having any existing disease, illness and had not received any treatment for the last 3 years and on the basis of this declaration, the medi claim insurance policy was issued to the complainant w.e.f. 28.5.2014 to 27.5.2015.  As per medical report dated 14.8p.2014 issued by Medanta Hospital, Gurgaon, the3 complainant had history of diabetes mellitus for 7-8 years and there was history of CAD for the last 3 years and the complainant had underwent PTCA.  As per family history of hypertension was for 3 years and he was admitted for intracerebral hemrage and the pre-existing disease diabetes mellitus and hyper tensioin are the main cause of the present disease.  As per details supplied by the complainant to Medsave Healthcare TPA Ltd., the complainant had not received any treatment prior to his admission in Medanta Hospital, Gurgoan.  The complainant in this way has concealed the above mentioned facts regarding pre-existing disease and thus, the expenses incurred on the treatment of the present disease is not covered under the terms and conditions of the insurance policy and thus, it cannot be said that there is any kind of deficiency in service on the part of the respondents.

          In support of these contentions, ld. Counsel for the respondents have relied upon the case law titled as LIC of India Versus Shahida Khatoon & Anr, CPC 2014(1) page 88 wherein it is held that from the evidence on record, insured was suffering from diabetes mellitus since 10 years when policies were obtained-The material fact was not disclosed-Violation of terms of insurance contract on the part of insured well proved-Repudiation justified.

          The Hon’ble National Commission in case titled as Kajol Vs. LIC of India and Chander Kanta Vs. LIC of India, CPC 2011(1) page 673  has held that It is settled law that burden to prove concealment of fact lies upon the insurer which has been duly discharged by the respondent-insurer-Insured gave false information relating to his health and treatment received from the hospital-There is no illegality in the order-Revision dismissed.

          Further the Hon’ble National Commission in case titled as LIC of India Vs. SS Jamuna, 2014(1) CPC page 670 has held that the material fact regarding pre-existing disease was suppressed when the policy was obtained-Parties are bound to comply with the terms of insurance contract-Violation of terms of policy well established-Claimant wrongly stated that death of insured was caused by accident-e

He died of a serious disease which was not disclosed-Repudiation of claim justified.

4.        After hearing both the learned counsel for the parties at length and after going through the entire relevant material available on the case file very carefully, we have come to the conclusion that there is deficiency in service on the part of the respondents.  As per the insurance policy, the complainant alongwith his wife was insured with the respondents for a sum of Rs.4 lacs for the period w.e.f. 28.5.2014 to 27.5.2015.  In the insurance policy, it is specifically mentioned:-

Past Inujry                  NA

Heart Disease                N

Existing Disability          NA.

 

In our view, the plea of the respondents at this stage that the complainant was having pre-existing disease is not tenable in the eyes of law.  Because to avoid any future complications, it was for the respondents to get the complainant medically examined from their approved panel of doctors and after getting themselves fully satisfied, to issue the insurance policy.   No documentary evidence has been led by the respondents to prove that the complainant was suffering from pre-existing disease.   The respondents also failed to produce any evidence to prove which medication and for how long the complainant was taking treatment for diabetes/hypertension.  In our view, the respondents cannot escape from their legal liabilities by taking such a lame excuses.  The observations of this Forum is fortified by the case law titled as New India Ass. Co. Ltd. Vs. Rakesh Kumar,  2014(III) CPJ 340 NC wherein the Hon’ble National Commission has held that “the OP did not produce any evidence to prove that which medication and for how long the complainant was taking treatment for diabetes/hypertension-OP cannot apply hard and fast rule to presume that the complainant was suffering from long duration i.e. before taking the policy-Concealment not established-Repudiation not justified.“

          So, taking into consideration the above cited law, we hereby allow the present complaint with the direction to the respondents to make the payment of Rs.4 lacs to the complainant alongwith interest at the rate of 09% per annum from the date of filing of the present complaint till realization.  The present complaint, thus, stands allowed.

          Certified copy of this order be provided to both the parties free of cost. File be consigned to the record-room.

 

(Prabha Wati)        (DV Rathi)                 (Nagender Singh-President)

Member DCDRF        Member DCDRF                   DCDRF, Sonepat.

Announced:08.06.2015