BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 565 of 2019
Date of Institution : 19.09.2019
Date of Decision : 20.07.2023.
Dr. Kewal Krishan Doda son of Shri Milakh Raj, resident of 50, M.C. Colony, Sirsa.
……Complainant.
Versus.
1. Cholamandlam MS General Insurance Company Limited, Regd Office : 2nd Floor, “Dare House”, N.S.C. Bose Road, Chennai- 600121 through its Divisional Manager.
2. Oriental Bank of Commerce, Near City Thana Sirsa, Tehsil and District Sirsa through its Branch Manager.
…….Opposite Parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
Present: Sh. Neeraj Narula, Advocate for the complainant.
Sh. H.S. Raghav, Advocate for opposite party no.1.
Sh. R.K. Chaudhary, Advocate for opposite party no.2.
ORDER
The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 (after amendment u/s 35 of C.P. Act, 2019) against the opposite parties (hereinafter referred as OPs).
2. In brief, the case of complainant is that op no.1 was in tie up with op no.2 that op no.2 would sell the mediclaim policy of op no.1 to its customers. The complainant is having a saving account no. 00682041000180 with op no.2 and he had obtained a medi claim from op no.2 issued by op no.1 under the scheme “Group Health Insurance” vide certificate No. 2842/00149968/0003/000/00 for the period w.e.f. 28.3.2018 to 27.3.2019 and paid Rs.7866/- as premium which was deducted by op no.2 from the above said account of complainant. That prior to issuance of the policy in question, complainant undergone all the tests as per policy of the ops. It is further averred that on 24.01.2019 when the complainant was performing his duty at Ayurjyoti Hospital and College, Jodhpuria, he suffered with dizziness and first aid was given to him at Ayurjyoti Hospital, Jodhpuria. Thereafter, he was shifted to Hope Neurocare Centre, Sirsa immediately where he was treated and operated by by Dr. Nitin Verma and was discharged on 6.2.2019. On 22.2.2019 complainant was shifted to Sarvodya Hospital, Hisar where he was operated by Dr. Umesh Kalra on 01.04.2019 and discharged on 11.04.2019 and he is still under treatment. That as per instructions of agent of op no.1 all the relevant documents alongwith claim form were sent to op no.1 on 22.2.2019 and his claim was registered with ops vide claim No. 2842077511. It is further averred that ops appointed Dr. Yogesh as Investigator who visited the hospital and collected all the relevant documents from hospital and from them and some more documents were also sent to op no.1 on 3.4.2019 on his demand. That thereafter complainant approached and requested the ops to pay his sum insured or expenses incurred by him on his treatment on many occasions but all in vain. The complainant remained busy in his treatment yet he remained demanding his claim amount from the ops but they did not bother for the same rather repudiated his claim vide repudiation letter dated 28.3.2019 and 23.4.2019 based upon wrong facts which is null and void and liable to be set aside. That act and conduct of the ops amounts to deficiency in service and unfair trade practice due to which complainant is suffering from harassment and mental agony. That complainant got served a legal notice upon ops but to no effect. Hence, this complaint.
3. On notice, ops appeared. Op no.1 filed written statement taking certain preliminary objections. It is submitted that complainant is suffering from hypertension from last several years prior to the inception of policy which was concealed by complainant at the time of inception of policy. The complainant has obtained Group Health Insurance Policy which covers the group of members and diseases suffered after commencement of policy. The claim of complainant has been closed due to pre existing disease which is clear from the report of doctors. It is further submitted that as per doctor statement, complainant is known case of HTN since 10 years, so due to aforesaid reason, the claim of complainant has been closed as old diseases are not covered under the insurance policy in question. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
4. OP no.2 also filed reply. While denying the contents of complaint, it is submitted that it is wrong and denied that complainant ever approached the answering op with any complaint for the non payment of claim amount by op no.1 and prayer for dismissal of complaint qua op no.2 made.
5. The complainant in evidence has tendered his affidavit Ex. P1 and documents i.e. certificate of insurance Ex.P2, certificate of doctor of Hope Neurocare Center Ex.P3, treatment record Ex.P4 to Ex.P7, repudiation letter dated 29.03.2019 Ex.P8, bills Ex.P9 to Ex.P12, claim form Ex.P13, Ex.P14, application dated 30.03.2019 Ex.P15, legal Ex.P16, postal receipts Ex.P17, Ex.P18 and adhar card Ex.P19.
6. On the other hand, op no.1 has tendered affidavit of Sh. Sujeet Kumar Sahu, Deputy Manager Legal as Ex. R1 and documents i.e. certificate of insurance Ex.R2, claim form Ex.R3, investigation report Ex.R4, Health claim query reminder letters dated 18.3.2019 Ex.R5, dated 2.3.2019 Ex.R6, dated 26.3.2019 Ex.R7, repudiation letter dated 23.4.2019 Ex.R8, discharge summary Ex.R9, emergency certificate Ex.R10, test reports and treatment record Ex.R11 to Ex.R14. Op no.2 did not lead any evidence.
7. We have heard learned counsel for the parties and have perused the case file carefully.
8. Undisputedly complainant had purchased Group Health Insurance Policy from op no.1 through op no.2 for himself, his wife Smt. Sudha Doda and son Shivam for the sum insured amount of Rs.3,00,000/- for the period 28.3.2018 to 27.3.2019 and premium amount of Rs.7866/- was paid by complainant to op no.1 through op no.2 as is evident from certificate of insurance Ex.P2. The doctor of Hope Neurocare Center in his certificate dated 06.02.2019 Ex.P3 has mentioned that patient Dr. Kewal Krishan i.e. complainant was admitted in their hospital on 24.1.2019 and was diagnosed with Left Parietal Hypertensive bleed which has paralysed. From the medical record of complainant placed on file, it is evident that complainant for the first time developed above said complication of his health only on 24.01.2019 i.e. during the period of policy and thereafter he remained on treatment for the above said disease. However, there is nothing on file to suggest that complainant was suffering from any pre existing disease and that complainant was having above said disease since long i.e. prior to the inception of the policy and he concealed this fact from the op no.1 insurance company. The op no.1 has not substantiated its version of pre existing disease of complainant through any cogent, convincing and reliable evidence. The op no.1 neither has placed on file any previous treatment record of the complainant nor has placed on record any affidavit of the doctor to prove the fact that complainant was having any pre existing disease. The op no.1 only on the basis of their assumption and presumption observed that signs and symptoms of the present ailment hypertension bleed is the complication which existing since 10 years i.e. prior to the inception of policy which is not substantiated on record through any cogent and convincing evidence rather from the above said certificate Ex.P3, it is proved on record that complainant suffered above said disease only on 24.01.2019 i.e. much after inception of the policy in question. The Investigator of the op no.1 in its report Ex.R4 has wrongly mentioned that as per audio recording with treating doctor, Insured was admitted for sudden loss of consciousness and underwent Lt FTP craniotomy and Insured might be suffering from DM probably last 5-10 years and that insured has not provided the exact duration of the same as said fact has not been proved on record by op no.1. No affidavit of the treating doctor in this regard has been placed on file by op no.1 and as such the version of Investigator cannot be relied upon. So, it is proved on record that op no.1 has wrongly and illegally repudiated the claim of complainant on the basis of false and frivolous grounds. It is also proved on record that complainant has spent huge amount on his above said treatment i.e. Rs.2,02,100/- in the hospital, Rs.8350/- on laboratory tests, Rs.64,509/- on medicines and Rs.8950/- on CT scan, x-ray and blood tests as is proved from bills Ex.Ex.P9 to Ex.P12 and complainant claimed above said amounts from the op no.1 vide claim form Ex.P13. So, the op no.1 has also wrongly mentioned in its letters that complainant has claimed amount of Rs.25,000/- only and in this regard wife of complainant also moved an application dated 30.3.2019 Ex.P15 that claimed amount of Rs.25,000/- mentioned by op no.1 is quite wrong and sought above said full claim amount. The act and conduct of the op no.1 clearly amounts to deficiency in service as well as unfair trade practice on its part due to which complainant has suffered unnecessary harassment. The complainant has spent total amount of Rs.2,83,909/- on his above said treatment and is entitled to said claim amount from op no.1. However, no liability of op no.2 bank towards the complainant is made out.
9. In view of our above discussion, we allow the present complaint qua the opposite party no.1 and direct the op no.1 to pay the claim amount of Rs.2,83,909/- ( in round figure Rs.2,83,900/-) to the complainant within a period of 45 days from the date of receipt of copy of this order, failing which complainant will be entitled to receive the above said amount of Rs.2,83,900/- alongwith interest @6% per annum from the date of this order till actual payment. We also direct the op no.1 to further pay a sum of Rs.10,000/- as composite compensation for harassment and litigation expenses to the complainant within above said stipulated period. However, complaint qua op no.2 stands dismissed. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced. Member President,
Dated: 20.07.2023. District Consumer Disputes
Redressal Commission, Sirsa.
JK
