Charanjit Singh, President;

1        The present complaint has been received from the District Consumer Disputes Redressal Commission Amritsar by the order of the Hon’ble State Consumer Disputes Redressal Commission Punjab, Chandigarh for its disposal.

2        The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section  11 and 12 against the opposite parties on the allegations that the complainant has purchased one medical Insurance policy from opposite parties bearing policy No. OG-16-1210-8417-00000034 against the payment of requisite premium amount. During the tenure of said policy period complainant has suffered from dengue and got admitted in Dukh Niwaran Hospital and Nursing Home Amritsar on 19.09.2016 and from where complainant discharged on 22.09.2016 and on the said medical treatment complainant had spent a sum of Rs.43,000/- approximately. In this respect requisite information/ intimation was given to opposite parties by complainant and the claim of complainant was under process with opposite parties vide claim No.64238253 and all the requisite documents were sent to opposite parties as per opposite parties requirement from time to time. In the month of November complainant got a call from company surveyor regarding claim investigation and complainant given him time at his home at 12:00 P.M  but he never met with complainant and rather in the absence of complainant he visited the premises of complainant two times and met complainant’s wife Sharanbir Kaur and took her statement in written which he dictated himself. The surveyor has given his report without meeting with complainant and also without investigating the matter by visiting the concerned hospital.  Inspite of the fact that complainant has provided all the requisite documents to opposite parties and has also fulfilled all the requisite formalities by way of sending all the relevant documents to opposite parties as per demands from time to time, but opposite parties have not taken into consideration all such facts, information and documents in a right manner and have  repudiated the claim of complainant on the basis of false and frivolous ground vide repudiation letter dated 16.12.2016 which itself has reflected deficiency in service. A legal and valid notice dated 24.05.2017 has also been served upon the opposite parties, but they have failed to comply with the said legal notice and even they did not bother to give any reply to the said legal notice which itself reflects malafide and dishonest intentions of the opposite parties and as such cause of action has arisen to file the present complaint against the opposite parties.  The complainant has prayed that necessary directions may kindly be given to the opposite parties to pay the above said amount of Rs.43,000/- approximately to the complainant spent by the complainant on this medical treatment  during the valid period of policy of Medical insurance alongwith interest @ 12% per annum and necessary directions be given to the opposite parties to pay compensation of Rs.50,000/- to the complainant. The costs of complaint be also granted to the complainant.

3        After formal admission of the complaint, notice was issued to Opposite Party and opposite party appeared through counsel and filed written version and contested the complaint by interalia pleadings that the complainant has concealed the material facts from this commission and has not come to the court with clean hands, therefore, he is not entitled for any claim. In this case as per medical record of the insured provided to the opposite party and from the investigation, it was found that medical record has been manipulated to give undue benefit to the complainant. As per doctor and ICP, patient was suffering from high grade fever, but WBC counts of patient as per lab report is within normal range, which shows that the facts have been manipulated by the hospital. It also proves from the facts that there is not proper medicine bill, no proper breakup, not showing batch number and no expiry date has been mentioned in the bills. In this case the medication has been shown in the form of syrup/tablets/capsules and only one injection Pentocid shown has been prescribed (OD) and given as per medication chart. The injection MVI has been mentioned in the drug chart, but there is not prescription for the same, similarly injection Metro and Injection Augmentin mentioned in the drug chart, whereas there is no prescription for the same. Moreover, when fever was improving, the injection kept increasing towards the discharge of the patient, which clearly shown that a false case has been made to get the claim and the documents have been tried to manipulate for the same. From the facts mentioned above, the complaint is liable to be dismissed. The hospitalization of the patient is only required where the patient is having low platelet count and high grade fever, but in the present case as per lab reports of the Dukh Niwaran Hospital and Sandhu Clinic, platelet counts and WBC are within normal range therefore, there was no need of hospitalization of the patient and the complainant is not entitled for any claim. As per medical record/ treatment given to the complainant and investigation of claim, it reveals that a false case has been made to get the claim, so in view of the facts mentioned above, the claim of the complainant was rightly repudiated vide letter dated 16.12.2016. The complainant is estopped by his own act and conduct from filing the present complaint. The complainant has no locus standi to file the present complaint. As per medical record/ treatment given to the complainant and investigation of claim, it reveals that a false case has been made to get the claim, so in view of the facts mentioned above, the claim of the complainant was rightly repudiated vide letter dated 16.12.2016. The opposite parties have denied the other contents of complaint and prayed for dismissal of the same.

4        The Ld. counsel for the complainant has placed on record affidavit of complainant Ex. C-1, copy of legal notice dated 24.5.2017 Ex. C-2, 4 Postal receipts Ex. C-3, Lab reports Ex. C-4, copy of the application dated 24.12.2016 Ex. C-5, copy of repudiation letter Ex. C-6, copy of discharge card Ex. C-7, copy of receipts Ex. C-8, copy of the report of SRL Diagnostics Ex. C-9 and closed the evidence. On the other hands, Ld. counsel for the opposite party tendered in evidence affidavit of Sarpreet Ahluwalia Ex. OP-1, affidavit of Sh. Gurpreet Singh investigator Ex. OP-2, Copy of investigation report Ex. OP-3, copy of the policy alongwith terms and conditions Ex. OP-4, copy of repudiation letter Ex. OP-5, copy of claim form Ex. OP-6, copy of discharge card of Dukhniwaran Hospital ex. OP-7, copy of the laboratory report Ex. OP-8, copy of the laboratory report Ex. OP-9 and closed the evidence. 

5        We have heard the Ld. counsel for the parties and have gone through the record on the file.

6        In the present case insurance is not disputed between the parties. As per complainant during the tenure of policy period he has suffered from dengue and got admitted in Dukh Niwaran Hospital and Nursing Home Amritsar on 19.9.2016 and from where complainant discharged on 22.9.2016 and on the said medical treatment complainant had spent a sum of Rs.43,000/- approximately and requisite information/ intimation was given to opposite parties by complainant and the claim of complainant was under process with opposite parties vide claim No.64238253 and all the requisite documents were sent to opposite parties as desired by opposite parties. The opposite parties have not given the claim to the complainant . Hence the present complaint. On the other hands, case of the opposite parties is that the complainant has concealed the material facts from this commission. From the investigation, it was found that medical record has been manipulated to give undue benefit to the complainant. As per doctor and ICP, patient was suffering from high grade fever, but WBC counts of patient as per lab report was within normal range, which shows that the facts have been manipulated by the hospital. It also proves from the facts that there is not proper medicine bill, no proper breakup, not showing batch number and no expiry date has been mentioned in the bills. In this case the medication has been shown in the form of syrup/tablets/capsules and only one injection Pentocid shown has been prescribed (OD) and given as per medication chart. The injection MVI has been mentioned in the drug chart, but there is not prescription for the same, similarly injection Metro and Injection Augmentin mentioned in the drug chart, whereas there is no prescription for the same. Moreover, when fever was improving, the injection kept increasing towards the discharge of the patient, which clearly shown that a false case has been made to get the claim and the documents have been tried to manipulate for the same. The opposite parties have appointed surveyor who investigated the matter and has given his report Ex. OP3 on record. In the report Ex. OP3 the investigator has given observations remarks as under:-

Though as per doctor, need for Hospitalization of patient is low platelet count and high grade fever but the platelet count as per lab Reports of Dukh Niwaran Hospital and Sandhu Clinic platelet count and WBC counts are within normal range hence need for Hospitalization of patient could not be justified.

Though as per Doctor and ICP patient is suffering from High Grade fever but WBC Count of patient as per lab reports is within normal range hence seems to be manipulation of facts by Hospital.

Though as per ICP fever of patient is of high grade but no Lab Report is confirming the facts. Vicinity check has been done but no one in vicinity has confirmed about the admission of patient.

SRL Labs refused to verify Reports.

Hospital refused to stamp signs the bills and told investigator that they have already provided it to patient but has shown the entries of bill.

As per insured he has no other Policy with him and no previous claims availed.

Though as per ICP and Doctor Statement, patient is admitted with High Grade Fever but WBC counts and platelet counts are normal in patient on the day of admission and during hospitalization hence need for Hospitalization could not be justified moreover SRL Labs refused to verify Reports.

Final Decision could be taken by the company as per above given discrepancies.

On the basis of above said report of investigator the opposite party has repudiated the claim of the complainant. The report Ex. OP3 is supported with affidavit of investigator namely Gurpreet Singh  which is Ex. OP-2. The Hon’ble National Commission held in “Suryachem Industries Vs. Oriental Insurance Co. Ltd.” I (2007) CPJ-278 (NC) that the surveyor report, being an important document, has to be given due weightage, unless rebutted by some cogent evidence on the record. The complainant has not produced any cogent and convincing evidence to rebut the report of the surveyor and there is no reason to disbelieve the said report. Accordingly, the complainant is not entitled to any claim as prayed for in the complaint and the opposite party has validly repudiated the claim of the complainant.

7        In view of above discussion, there is no merit in the present complaint and the same is hereby dismissed with no order as to costs. Copy of order be supplied by the District Consumer Disputes Redressal Commission, Amritsar as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar.

Announced in Open Commission

21.10.2022