Chandigarh

StateCommission

A/204/2019

Fortis Hospital - Complainant(s)

Versus

Dalip Kumar - Opp.Party(s)

Munish Kapila Adv.

22 Nov 2021

ORDER

 

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

UNION TERRITORY, CHANDIGARH

 

Appeal No.	204 of 2019
Date of Institution	12.09.2019
Date of Decision	22.11.2021

Fortis Hospital, Sector 62, VII, Mohali – 160062, through its MD or its Authorized representative.

                                   …..Appellant/Opposite Party No.3

 

Versus

1. Sh. Dalip Kumar, Shop No.23, Gupta Complex, Landmark Opp. Hanuman Mandir Baddi Town, Solan, Himachal Pradesh.

…..Respondent/Complainant

2. Cigna TTK Health Insurance Company Limited, 401/402, Rehjea Titanium, Western Express Highway, Goregaon (East), Mumbai – 400063, through its MD or Authorized Representative.
3. Cigna TTK Health Insurance Company Limited, 1^st Floor,
   SCO 149/150, Sector 9-C, Chandigarh – 160009 through its Authorized representative.                           

 …..Respondent/Opposite Parties No.1 & 2            

BEFORE:  JUSTICE RAJ SHEKHAR ATTRI, PRESIDENT

                MRS. PADMA PANDEY, MEMBER

                MR. RAJESH K. ARYA, MEMBER

               

Argued by:  Sh. Munish Kapila, Advocate for the appellant.

Sh. D.D. Taneja, Advocate for respondent No.1.

Sh. Inderjit Singh, Advocate for respondents No.2 & 3.

                                

PER PADMA PANDEY, MEMBER

              This appeal is directed against an order dated 02.08.2019, rendered by District Consumer Disputes Redressal Forum-I, UT, Chandigarh, now District Commission (hereinafter to be called as the District Commission only), vide which, it partly allowed the Consumer Complaint, filed by the complainant, with the following directions: -

 “i. OPs 1 & 2 to pay the amount of Rs.34,819/-to the complainant alongwith interest @ 9% per annum from the date of repudiation i.e. 29.7.2017 till realization.

2. OP-3 to pay an amount of Rs.20,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. OP-3 to pay Rs.15,000/- to the complainant as costs of litigation.

The relief of complainant is complete. In view of observations made in order, OP-3 needs to be economically punished for its reckless behaviour, highlighted above.  Hence, OP-3 is further directed as under :-

4. OP-3 to also deposit an amount of Rs.1,00,000/- as punitive damages in the Consumer Legal Aid Fund account being maintained in the name of Secretary, State Consumer Disputes Redressal Commission, UT, Chandigarh for help of poor consumers who are in need of legal aid.
   17. This order be complied with by the OPs severally within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i), (ii) & (iv) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.”

 

2. The facts, in brief, are that the respondent No.1/complainant had purchased a medical insurance plan under the name “ProHealth-Accumulate’ of respondent/Opposite Party No.1 through respondent/Opposite Party No.2 on payment of premium and the said policy was valid from 02.06.2017 to 01.06.2018 (Annexure C-1).  It was stated that on 03.06.2017, complainant had felt pain in left side of chest radiating from left shoulder and arm and he got himself admitted with respondent/appellant for treatment and on improvement, he was discharged on the very next day on clearance of the bill of Rs.34,819/- to the appellant.  It was further stated that claim was submitted to Opposite Parties No.1 & 2/Respondent Nos.2 & 3, but it was not processed as they repudiated it on the grounds that the complainant suffered from DM diabetes and CAD, which were pre-existing and, therefore, it was not allowed.  It was further stated that there was wrong medical report of appellant/Opposite Party No.3 of respondent No.1/complainant being patient of diabetes mellitus.  It was further stated that he had also obtained a certificate from the appellant/Opposite Party No.3 that he was not suffering from any diabetic disease.  It was further stated that legal notice was sent but to no avail.  It was further stated that the aforesaid acts of the Opposite Parties, amounted to deficiency, in rendering service, as also indulgence into unfair trade practice. When the grievance of the complainant, was not redressed, left with no alternative, a complaint, was filed.
3. The Opposite Parties No.1 & 2 filed their joint reply and stated therein that the complainant had suffered from pre-existing disease prior to the policy and he was having diabetes or pre-diabetes conditions for the last six months which facts were suppressed by the complainant at the time of purchase of policy.  It was further stated that the case of the complainant fell in exclusion clause and, therefore, the claim was repudiated. It was further stated that there is no deficiency in service on their part, and the aforesaid Opposite Parties/respondent No.2 & 3 had prayed for dismissal of the complaint.
4. Opposite Party No.3 filed its reply and admitted the factual matrix of the case.  It was stated that Bill was raised of Rs.34,819/- which was paid  by the complainant.  It was further stated that the answering Opposite Party has no concern with the allegations made in the complaint and therefore, there is no deficiency in service or unfair trade practice on their part, Opposite Party No.3/appellant has prayed for dismissal of the complaint.
5. In the rejoinder, filed by the complainant, he reiterated all the averments, contained in the complaint.
6. The parties led evidence, in support of their case.
7. After hearing the Counsel for the Parties, and, on going through the evidence, and record of the case, the District Commission, partly allowed the complaint against Opposite Parties/appellant and Respondent No.2 & 3, as stated above.
8. Feeling aggrieved, the instant appeal, has been filed by the appellant/Opposite Party No.3.
9. We have heard the Counsel for the parties, and have gone through the evidence, and record of the case, carefully.
10. After giving our thoughtful consideration, to the contentions, advanced by the Counsel for the parties, and the evidence, on record, we are of the considered opinion, that the appeal is liable to be dismissed, for the reasons to be recorded hereinafter.
11. On examination of the documents of the learned District Commission, this Commission finds that ground of repudiation of the claim of complainant/respondent was based on the disclosure of getting treated for Diabetes Mellitus Type-2 clearly written in the discharge slip, furnished by the appellant. Annexure OP-3/2 final diagnosis of Opposite Party No.3/appellant was HTN DM Type-2, which clearly shows that it was the own diagnosis of Opposite Party No.3/appellant for which the complainant/respondent No.1 was treated. We find that Opposite Party No.3/appellant has taken inconsistent, contradictory stand that they were told so by the complainant/respondent No.1 at the time of admission while the record of the appellant/Opposite Party No.3 shows that it was their own diagnosis. The complainant/respondent No.1 had also furnished an affidavit that he had not disclosed such disease to the appellant. Further, a certificate vide Annexure C-6, has been issued by the appellant to the complainant, is reproduced as under:-

“This is to certify that Mr. Dilip Kumar was being observed by me for last 3 years.

He has never been diabetic (No diabetes till date).”

12.  This shows that there is contradictory stand taken by the appellant/Opposite Party No.3 which caused mental harassment to the complainant/Respondent No.1 and the learned District Commission has rightly allowed the complaint partly with the directions as mentioned above, which does not warrant interference by this Commission and therefore the appeal is dismissed.
13. No other point, was urged, by the Counsel for the parties.
14. For the reasons recorded above, the appeal, being devoid of merit, must fail, and the same is dismissed, with no order as to costs. The order of the District Commission is upheld.
15. Certified copies of this order, be sent to the parties, free of charge.
16. The file be consigned to Record Room, after completion.

 

Pronounced.

22.11.2021

 

                                                              Sd/-

                        [JUSTICE RAJ SHEKHAR ATTRI]

PRESIDENT

 

Sd/-

 [PADMA PANDEY]

MEMBER

Sd/-

[RAJESH K. ARYA]

 MEMBER

 

GP