Delhi

Central Delhi

CC/197/2016

MEENU GURJAR - Complainant(s)

Versus

HDFC ERGO G. INS. CO. LTD. - Opp.Party(s)

10 May 2024

ORDER

Heading1
Heading2
 
Complaint Case No. CC/197/2016
( Date of Filing : 23 May 2016 )
 
1. MEENU GURJAR
H. NO. 45, G.FLOOR, AMRITPURI, GARHI, EAST OF KAILASH, NEW DELHI-24.
...........Complainant(s)
Versus
1. HDFC ERGO G. INS. CO. LTD.
10th FLOOR TOWER -B, BUILDING NO. 10, DLF CYBER CITY, DLF CITY, PHASE -II, GURGAON, HARYANA-122002.
............Opp.Party(s)
 
BEFORE: 
 HON'BLE MR. INDER JEET SINGH PRESIDENT
 HON'BLE MS. RASHMI BANSAL MEMBER
 
PRESENT:
 
Dated : 10 May 2024
Final Order / Judgement

Before  the District Consumer Dispute Redressal Commission [Central], 5th Floor                                                   ISBT Building, Kashmere Gate, Delhi

                                      Complaint Case No. 197/23.05.2016

 

Meenu Gurjar (dead) through her LRs-

(a) Shri Sheel Gurjar (husband)

(b)Shri Adurvrat Basatta (son)

(c)Ms Ishna Basatta (daughter)

All r/o House No.5479, Gali no.6.

Village New Chandrawal, New Delhi-110007                                 …Complainant

 

                                                Versus

HDFC Ergo General Insurance Company Limited

[erstwhile name Apollo Munich Health Insurance Company

Limited/ HDFC Ergo Health Insurance Limited]

HDFC House, 1st Floor, 165-166, Backbay Reclamation,

H.T. Parekh Marg, Churchgate, Mumbai, Mumbai City,

Maharashtra-400020                                                                          ...Opposite Party

 

                                                                                    Date of filing              23.05.2016

                                                                                    Date of Order:           10.05.2024

Coram:  

Shri Inder Jeet Singh, President

Ms Rashmi Bansal, Member -Female

                                               

                                                       ORDER

Inder Jeet Singh , President

 

1.1. (Introduction to case of parties) - The complainant/Insured filed the complaint against Insurer/OP by making allegations of poor services and deficiency of services of firstly declining her cashless facility for medical bills and subsequently declining of reimbursement of medical bills despite it were covered under Health Insurance Policy

The complainant seeks amount of Rs.2,80,000/- being reimbursement of medical bills of treatment, compensation of Rs.50,000/- in lieu of harassment, mental agony and sufferings, apart from litigation costs of Rs. 11,000/- and other appropriate relief under the circumstances.

1.2. The OP opposes the complaint by denying allegations of poor or deficiency of services and also justifies to decline of claims. The pre-authorised was rightly declined and then claim was also declined as per terms of policy, since the complainant had suppressed material facts in the proposal form and also failed to provide documents of treatment despite repeated requisition/reminders/letters.  The policy was obtained by false declaration and against the principles of utmost good faith. It cannot be construed deficiency of services and complainant is not entitled for any claimed amount.

1.3  During the pending of complaint, there was merger of initial OP (Apollo Munich Health Insurance Co. Ltd.) into HDFC Ergo Health Insurance Ltd. as well as there is change of name consequent to certificate of incorporation pursuant to change of name, accordingly the name of HDFC Ergo General Insurance Co. Ltd. is arrayed.

1.4   Further, the complainant had also died during the pending of this complaint, thus names of her LRs were brought by order dated 30.09.2019, which are mentioned in the array of parties.

 

2.1. (Case of complainant) – The complainant has been regular policy holder of OP since 2011-12 till date and she has been regularly paying the premium for each policy of year 2011-12, 2012-13, 2013-14  and 2014-15, since the policy was being renewed regularly. The complainant was issued health insurance policy no. 110102/11001/1000233359-03 through SPA Retail, Noida (being intermediary having code no. 80096430) for period 16.10.2014 to 15.10.2015 for sum insured Rs. 2 lakh against premium of Rs. 4,085.32p, having cumulative bonus of Rs.60,000/- (as shown in the policy), however, it was told that cumulative of policy would be Rs.80.000/-.

2.2.  On 27.04.2015 the complainant was admitted in Holy Family Hospital since she was deducted ovarian cancer in April 2015. She was provided treatment of cancer at Holy Family Hospital in April 2015 but complainant was not extended health insurance policy benefit, since then she has been running from pillar to post for settlement of her claim.

            At the time of taking insurance policy of OP, the complainant had provided all information to the agent of OP that complainant’s uterus and one ovary was removed in the year 2010 and after such information the OP had issued the insurance policy. The complainant was asked and she had provided previous discharge  summary of Dwarka Ayushman Hospital, Delhi, biopsy report of operation, Chemo report, other relevant documents and information in respect of Batra Hospital, Delhi for taking benefit under the insurance policy. Moreover, after complainant’s treatment in Holy Family Hospital at Delhi, the concerned agent of OP started asking various documents from the complainant including biopsy report, etc. since April 2015. Thus all documents and information were provided to the OP through concerned agent in May 2015.

2.3  The complainant has been pursuing hard to the OP to take benefit under the insurance policy but all went in vain. The complainant has also requested the OP time and again to look into the matter but of no avail. Thus, complainant has been caused physical and mental harassment because of indifferent attitude of agent/officer of OP, since she was cancer patient and needed sympathy and kindness. There are poor services and deficiency of services by the OP, the complainant suffered heavy financial burden and losses, she is at the mercy of her close relatives having very meager sources as her husband is not supporting being alcoholic. The complaint also narrates other circumstances in respect of complainant and her children that they are facing starvation being at the mercy of other. That is why the complaint for claim of Rs. 2,80,000/- on account of medical treatment for cancer and allied claims, claim of Rs. 50,000/- in lieu of harassment and mental agony caused by OP besides interest of 18%pa, litigation charges of Rs. 11,000/- and other relief, since OP failed to settle the claim despite legal notice dated 12.10.2015.

2.4. The complainant is accompanied with record of insurance policy issued, copy of discharge summary and other papers of Batra Hospital, Holy Family Hospital, Dwarka Ayushman Hospital, summary bill and legal notice with postal receipts.

 

3.1 (Case of OP)- The OP filed detailed written statement, it is composite of preliminary objections, preliminary submission and reply on merits  besides citation of case law (the citation will be mentioned at appropriate stage of this final Order).

3.2. The OP denies allegations of deficiency of service and it is not liable on any count towards the complainant. The complaint is false, mala-fide and abuse of process of law since an attempt is being made by the complainant to extract money from OP as well as the complainant intends to avail undue advantage. There is no cause of action in her favour and against the OP.

3.3. The complainant obtained medical policy by suppressing material facts of status of her health & ailment and that information was suppressed from the proposal form while applying for insurance policy. From the medical documents of complainant, it was revealed that she had not made full and complete disclosure at the inception of policy. Thus, based on such non-disclosure of material facts at the time of availing the policy, the claim is not made out. The complaint is without cause of action and merits.

3.4. The contract of insurance is based on principles of utmost good faith and complainant was required to disclose every material fact, otherwise this becomes good ground for recession of contract. The complainant was very well aware of her medical conditions but she choose to not to disclose of correct facts in the proposal form. The written statement further elaborates about the meaning of material fact or consequences of non-disclosure of the same, while referring  decided cases that  there is obligation of complainant to disclose all material particulars to enable the insurer to form opinion, whether or not risk is to be undertaken.

3.5 The OP does not deny about the insurance policy no.110102/11001/1000233359 cover issued to the complainant based on proposal form  but allegations of deficiency of services are denied as well as to justify that the declining of claim was because of concealment of material facts from the proposal form about the status of health and ailment of complainant. There is specific question in paragraph no.6 pertaining to tumor benign or malignant, any ulcer/growth/cist and also another  sub-paragraph whether the complainant had undertaken any surgery or it was advised in the last 10 years or a surgery still pending, in response thereto the complainant had responded in 'negative'. Moreover, the complainant was also provided kit of insurance policy and its section 7/General condition is regarding supporting document and examination, which mandates the complainant to provide all the relevant material and  other document and information.

3.6.1 On 28.04.2015, there was cashless request received from Holy Family Hospital, New Delhi  on behalf of complainant and on scrutiny/review of record, it was asked to justify the need of hospitalisation since the complainant was admitted with complaint of abdominal pain for one day and probable diagnosis of acute abdomen but there was requirement of stay of 3 days. The additional information was sought, however, it was not provided and cashless facility was declined. Then complainant submitted claim for reimbursement of Rs. 38,383/- and on reviewing the documents, it was noticed that the patient was admitted for management of right ovarian mass, hypothyroidism and underwent medical condition managed and she was discharged with advice. Further, it was also noted that the documents furnished were not sufficient to process the claim and in order to more clarity, the OP was asked more documents (viz. biopsy report of ovary done in 2010, copy of cancelled cheque with other related record, original balance cash pay receipt of final bill) and for want of providing the same,  the complainant was written reminders dated 24.06.2015, 09.06.2015, 02.07.2015 and for want of furnishing them,  the claim was closed.

3.6.2  On 12.05.2015 another cashless requests was received from Holy Family Hospital on behalf of complainant that on provisional diagnosis, the complainant was admitted with complaint of abdominal pain and probable diagnosis right ovarian mass with the date of admission of 14.05.2015 and approximate stay would be for 3 days with estimated of Rs. 65,000/-. On the same day additional information was sought. On reviewing the documents most particularly discharge summary and final bill, it was noticed that complainant was admitted for investigation and in valuation purposes, the cashless facility was declined, with an advice that  she may file claim for reimbursement with all required medical and financial documents. On 01.06.2015 claim of reimbursement of Rs.  29,484/- of second hospitalisation was lodged and the complainant was asked to furnish documents (viz. biopsy report of ovary done in 2010, copy of cancelled cheque with other related record) but the same were not furnished and reminders dated 09.06.2015, 24.06.2015  and 02.07.2015  were also sent and for want of any response, this claim was closed.

3.6.3 On 10.06.2015 another cashless requests was received from Batra Hospital and Research Centre on behalf of complainant under the said policy, that she was provisionally diagnosed and admitted of complaint of granulose cell tumor of ovary and she was admitted on 10.06.2015  with approximate stay of requirement of 4 days against estimated expenses of Rs. 42,000/-. After reviewing the document it was asked for documents of clarity (viz. exact duration of carcinoma, when it was first diagnosed; histopathological examination of right ovarian cystectomy and hysterectomy done in 2010, treating doctor’s certificate and 1st consultation prescription for history/exact duration of present illness with all past treatment records, all investigation reports of patient supporting the diagnosis, admission notes, treatment chart and vitals). But the complainant failed to provide the same and cashless request was rejected with an advice to file appropriate claim with documents for  reimbursement. On 18.07.2015  the claim was submitted for Rs. 72,381/- and it was reflecting that patient was admitted for management of metastatic granulose cell tumor and ovary and underwent chemotherapy. The complainant was asked to provide the documents (all investigations, treatment and follow up record pertaining to hypothyroidism and gastrointestinal reflux disease since first diagnosis and all other treatment record & discharge summary when she had hysterectomy 4 years back. Biopsy report done in 2010). The record was not provided despite reminders dated 28.07.2015. 12.08.2015 and 20.08.2015, thus claim was rejected besides cashless facility was declined.  

3.6.4.  On 03.07.2015  another cashless requests was received from Batra Hospital and Research Hospital, on behalf of complainant on provisional diagnosis, the complainant was admitted with complaint of metastatic granulose with admission on 03.07.2015 for approximately stay for 4 days with estimated expenses of Rs. 45,600/-, however, on the basis of circumstances, additional information was sought and biopsy report done in 2010, investigation report supporting the latest malignancy but complainant failed to provide the documents, the cashless request was rejected, with an advice the complainant may file the claim with required medical and financial document for reimbursement so that claim may be processed on merits, it was claim of Rs. 72,381/-. However, the documents furnished were not sufficient (since the complainant was admitted in hospital for management of metastatic granulose cell tumor of ovary and underwent chemotherapy), the documents were asked of all investigation, treatment and follow up record pertaining to hypothyroidism, gastrointestinal decease, treatment record including discharge summary, when she had hysterectomy of 4 year back and biopsy report in 2010  but there was no compliance, even reminders dated 28.07.2015, 12.08.2015 and 20.08.2015  were not responded and claim was closed.

 

3.7  The OP denies all other allegations in the complaint either of furnishing information or of documents to the agent at the time of taking policy or cumulative bonus would of Rs. 80,000/- or documents were provided about removal of uterus and one ovary in 2010. The complaint is also opposed for suppression of material information from the proposal form as well as for want of furnishing documents pertaining to claim for the first hospitalisation, claim for the second hospitalisation, claim for the third hospitalisation and claim for the fourth hospitalisation. There is violation of very fundamental of law of contract since it is not binding upon the OP as material  information supposed to be furnished was withheld and insurance policy was obtained on false declaration  (the OP also refers case law, the same will be referred appropriately). The very basis of insurance contract is proposal form, however, the statement and declaration made in the proposal form were not correct and consequently it is not binding on the OP; the insurance contract is based upon utmost good faith but it is breached by the complainant. The complaint is liable to be dismissed.

3.8 The reply is supported by proposal form, schedule of information, terms and conditions of policy, claim forms with copies of letters seeking additional information, denial of cashless facility, reminders and rejection of claim. (but it is relevant to mention that in the written statement the OP refers the Annexures R1 to R6, however, there is no Annexure-R4; to say  there are Annexure R1 to R3, R5 & R6).

4.1  (Evidence)- The complainant Ms. Meenu Gurjar led her exclusive evidence by way of her detailed affidavit with the support of documents already filed with complaint. It is reminded that at the time of leading evidence, the complaint was alive.

4.2. The OP also led its evidence by filing detailed affidavit of Deepti Rustagi Attorney of erstwhile OP,  it is replica of reply to complaint.

 

5. (Final hearing)- Both the parties have filed their written arguments. At the stage of oral submissions, Sh. Rajbir Bansal, Advocate for complainant and Sh. Suman Tripathi, Advocate for OP made their respective submissions. Moreover, the OP fortifies its case and derives reasons in its support from the following cases:-

(i) P C Chcko & antr Vs Chairman, LIC Ltd (AIR 2008 SC 424), held that contract of life insurance are contracts of utmost good faith, every material fact must be disclosed, other there is good ground for recession of the contract.

 

(ii) Haji Ahmed Yar Khan vs Abdul Gani Khan (AIR 1937 Nag 207 at 272) and Mithoolal Nayank Vs LIC AIR 1962 SC 814  while adjudicating on sec. 4 of the Insurance Act, 1938, it was held, three conditions for later part of section 4 are,  the statement must be on material matter, or must suppress facts which it was material to disclose, the suppression must  have known at the time of making the statement that it was false or that it was false or that it suppressed facts which was material to disclose.

 

(iii)  United India Insurance Co. Ltd. Vs. Subhash Chandra RP No. 469/2006 dod 19.5.2010 - held, principle of insurance is fundamental to utmost good faith, which must be observed by the contracting parties and utmost good faith , forbids either party from non-disclosure of the fact which parties know and either of the parties have a duty to disclose all material facts in their knowledge, failing which it amounts to deliberate suppression of material facts.

 

(iv) LIC Vs Satwant Kaur Sandhu RP no.3138/2006 dod 13.01.2011-
'when information on a specific aspect is asked for in the proposal form, the assured is under a solemn obligation to make a true and full disclosure of the information on the subject which is within his knowledge. An inaccurate answer will entitle the respondent to repudiate its liability because there is clear presumption that any information sought for in the proposal form is material for the purposes of  entering into contract of insurance.                                  .
 

6.1 (Findings)- The  contentions of the parties are considered keeping in view documentary and other evidence of parties, case law referred and relied upon.  It does not require to be reproduced, as their rival contentions will be appreciated while analyzing and weighing the evidence.

6.2. It is manifest from plain reading of case of parties, that the relationship of the complainant and of the OP are of the Insured and the Insurer respectively. There is also no dispute of previous policies issued from time to time, the last policy, its tenure and premium paid.  It is also not disputed that the complainant had undergone treatment, also as an indoor patient, in Dwarka Ayushman Hospital in December 2010, the Holy Family Hospital in April 2015 and May 2015 and Batra Hospital during June 2015 and July 2015 as well as the complainant had paid the entire medical bills  since cash-less facility was not extended by OP.

6.3. However, the consumer dispute is   "whether or not the complainant had medical condition, which was not declared in the proposal form and concealed it from the OP?  and "whether or not  the complainant is entitled for insurance claim and other reliefs"?  To determine these issues, it needs to access and analyze the evidence, whether there was any medical conditions prior to obtaining insurance policy, whether it was disclosed by the complainant and if not, what would be the consequences under the policy?. 

            It is appropriate,  for the sake of appreciation of case of parties,  to  refer law laid down in "Jagdish Vs LIC of India [FA no.1055/2003 dod 17.12.2007, decided by Hon'ble State Commission]", in which circumstances and parameters of pre-existing disease were laid down in detail, its paragraph 10 is reproduced -

"Para 10 -Our conclusions on the meaning and import of words disease, pre-existing
disease for the purpose of medi-claim insurance policy, as under:
 

(i) Disease means a serious derangement of health or chronic deep-seated disease
frequently one that is ultimately fatal for which an insured must have been hospitalized or operated upon in the near proximity of obtaining the medi-claim policy,


(ii) Such a disease should not only be existing at the time of taking the policy but also
should have existed in the near proximity. If the insured had been hospitalized or operated upon for the said disease in the near past, say, six months or a year he is supposed to disclose the said fact to rule out the failure of his claim on the ground of concealment of information as to pre-existing disease,

 
(iii) Malaise of hypertension, diabetes, occasional pain, cold, headache, arthritis and
the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day to day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease,


(iv) If insured had been even otherwise living normal and healthy life and attending to
his duties and daily chores like any other person and is not declared as a diseased person as referred above he cannot be held guilty for concealment of any disease, the medical terminology of which is even not known to an educated person unless he is hospitalized and operated upon for a particular disease in the near proximity of date of insurance policy say few days or months,


(v) Disease that can be easily detected by subjecting the insured to basic tests like
blood test, ECG etc. the insured is not supposed to disclose such disease because of otherwise leading a normal and healthy life and cannot be branded as diseased person,

 

(vi)  Insurance company cannot take advantage of its acts of omission and commission as it is under obligation to ensure before issuing medi-claim policy whether a person is fit to be insured or not. It appears that insurance Companies do not discharge this obligation as half of population is suffering from such malaises and they would be left with no or very little business.

Thus any attempt on the part of the insurer to repudiate the claim for such non-disclosure is not permissible, nor is exclusion clause invoke-able,


(vii) Claim of any insured should not be and cannot be repudiated by taking a clue or
remote reference to any so-called disease from the discharge summary of the insured by invoking the exclusion clause or non-disclosure of pre-existing disease unless the insured had concealed his hospitalization or operation for the said disease undertaken in the reasonable near proximity as referred above,

 

(viii) Day to day history or history of several years of some or the other physical problem
one may face occasionally without having landed for hospitalization or operation for the disease cannot be used for repudiating the claim. For instance an insured had suffered from a particular disease for which he was hospitalised or operated upon 5, 10 to 20 years ago and since then had been living healthy and normal life cannot be accused of concealment of pre-existing disease while taking medi-claim policy as after being cured of the disease, he does not suffer from any disease much less the pre-existing disease,


(ix) For instance, to say that insured has concealed the fact that he was having pain in
the chest off and on for years but has never been diagnosed or operated upon for heart disease but suddenly lands up in the hospital for the said purpose and therefore is disentitled for claim bares dubious design of the insurer to defeat the rightful claim of the insured on flimsy ground. Instances are not rare where people suffer a massive attack without having even been hospitalised or operated upon at any age say for 20 years or so,


(x) Non-disclosure of hospitalization/or operation for disease that too in the
reasonable proximity of the date of medi-claim policy is the only ground on which insured claim can be repudiated and on no other ground.
 

6.4.    Since there is dispute of medical condition and disclosure in the proposal form, thus both of them are inter-related with each other, they are required to be discussed together, that is why they are being taken together. After considering facts, features, evidence of parties along-with the settled law analytically, the following conclusions are drawn:-

(a) The complainant as well as the OP have filed insurance policy cover w.e.f. 16.10.2014 to 15.10.2015.  OP has also proved proposal form dated 26.08.2011 signed by the complainant, which was first time subscribed by the complainant. The policy holder is complainant and her husband is nominee in the policy.

 

(b)  The complainant had undergone treatment at Holy Family Hospital in April 2015 and May 2015 and then in Batra Hospital in June 2015 and July 2015, these tenure of treatment are within the currency of insurance policy.

 

(c)  The complainant was brought to emergency of Holy Family Hospital on 17.04.2015 and later remained there as indoor patient. It is emergency card but  no record of discharge summary was filed to show the history of ailment, examination and procedure. The emergency card mentions prescriptions and advises. However, the complainant has not filed the discharge summary of her treatment in April 2015 and May 2015 in the Holy Family Hospital to evaluate the totality of circumstances.

 

(d) The complainant has proved discharge summary dated 13.06.2015  in respect of her treatment from 10.06.2015  to 13.06.2015 in the Batra Hospital and also another discharge summary for her treatment in Batra Hospital from 03.07.2015  to 04.07.2015. She was diagnosed of Metastatic Granulosa Cell tumor of ovary on both the occasions.  Moreover, it has been specifically recorded that the patient had undergone hysterectomy 4 years back.

 

(e) It is an admitted case of complainant that she had treatment in Dwarka Ayushman Hospital in the year 2010 when her uterus and one ovary was removed.

 

(f) The OP has proved proposal form dated 26.08.2011, which is under the signature of complainant and in paragraph-6 thereof (medical and life style information) there is a specific query/column of tumor benign or malignant/ulcer/growth/cyst, it was responded in negative.

It is settled law, by case of Jagdish Vs LIC of India [FA no.1055/2003(supra)], when the complainant has been leading normal life after treatment of previous ailment then it cannot be treated as pre-existing medical condition or disease.

 However, if at the time of filling in the proposal form, the disease have been either in continuation or in proximate of time immediately before the proposal form then it would be a case of pre-existing disease and it becomes obligatory on the part of proposer to disclose the same in the proposal form. By reading the chronology of treatment of the complainant from Dwarka Ayushman Hospital onwards of the same medical issue, it shows that the complainant been under continuous treatment. In other words in the year 2010 the uterus and ovary of the complainant was removed and the discharge summary issued by Batra Hospital also mentions that complainant had undergone hysterectomy 4 year back as well as the treatment in Holy Family Hospital is for same ailmment/disease but the complainant had withheld discharge summary issued by Holy Family Hospital.

            However, the discharge summary dated 13.06.2015 issued by Batra Hospital mentions the history of immediate previous treatment that complainant had pain in abdomen x 2 weeks with vomiting. Diagnostic laparoscopy with biopsy of interparietoneal deposits under GA (15.05.15) revealed compactable with metastatic granulos cell tumor. Patient was admitted for 1st cycle of chemotherapy on 11.06.2015.  In the subsequent discharge summary of 04.07.2015 by the Batra Hospital, it is in continuation of previous history of patient that patient was started on D1 of 1st cycle of chemotherapy on 11.06.2015  with injection and the patient was admitted for 2nd cycle of chemotherapy.    

 

(g) The series of events are showing that complainant has been undergoing the treatment of the same disease from the year 2010. Further, in view of settled law and facts discussed hereinabove, the case of complainant is to be construed a case of existence of medical history and continuous treatment.

 

(h) The first insurance policy was from period 2011-12 and the proposal form was furnished on 26.08.2011. The complainant had under removal of uterus and one ovary in 2010, which is immediate to the policy period of 2011-12.

 

6.5 Consequently the other question is "whether or not  there is concealment of/ suppression of such medical condition in the proposal form"?.

            The proposal form has been proved by the OP and it is under the signature of complainant (medical and life style information) there is a specific column of tumor benign or malignant/ulcer/growth/cyst, it was responded as ‘No’ by the complainant.  The plea of OP that principle of utmost good faith has been breached by the complainant by making answer in negative of material fact, it is concealment of disease and treatment. Thus, it is held complainant had concealed this fact and information, which would affect the decision of OP to undertake policy or not.  The sub-clause (x) in Jagdish Vs LIC of India case (supra) is about non-disclosure of hospitalization/or operation for disease that too in the reasonable proximity of the date of medi-claim policy is the only ground on which insured claim can be repudiated and on no other ground. The first insurance policy was from period 2011-12 and the proposal form was furnished on 26.08.2011. The complainant had undergone removal of uterus and one ovary in 2010, which is immediate to the policy period of 2011-12.

6.6  The complainant was asked by the OP for additional information and documents when cashless facility was requested by the concerned hospital as well as subsequently when complainant has lodged claims, after her discharge on all four occasions. Moreover, the OP has also proved letters and reminders for additional information and documents, however, the same were not furnished to the OP. Moreover, it is also apparent that in the present complaint, when such objections were taken by the OP, those record of year 2010 or of discharge summary of Holy Family Hospital were not furnished. The medical record and discharge summary issued by Batra Hospital contain reference of features of contemporary period but the same were not provided to the OP to process the claim appropriately. Moreover, it is also the condition in the policy to provide documents, it was not complied with by the complainant. It would not be out of context to mention that the complainant had filed bills or final bills but they are not substitute of previous medical record sought, of the year 2010 or of discharge summary issued by Holy Family Hospital. Although, the circumstances of treatment undergone at Holy Family Hospital in May 2015 are briefly mentioned in the discharge summary issued by Batra Hospital.

7. So, the complainant failed to establish her case either of poor services or of deficiency of services or of her claim to be within the purview of insurance policy. The complaint fails. The complaint is dismissed. No order as to costs.  

 

8. Announced on this 10th day of May 2024 [वैशाख 20, साका 1946].  Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for necessary compliance.

 

                                                                                                                            [Rashmi Bansal]                                        

                                                                                                                         Member (Female) 

 

                                                                                                                          [Inder Jeet Singh]

                                                                                                                                        President

[ijs-51]

                                        

                                              

 

         

 
 
[HON'BLE MR. INDER JEET SINGH]
PRESIDENT
 
 
[HON'BLE MS. RASHMI BANSAL]
MEMBER
 

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