Haryana

StateCommission

CC/35/2015

SYED SAMMAR ABBAS - Complainant(s)

Versus

ICICI LOMB.GEN.INSURANCE CO. AND ANOTHER - Opp.Party(s)

MADHU RANJAN

27 Jan 2017

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

Complaint No     :    35 of 2015

Date of Institution:  09.04.2015

Date of Decision :   27.01.2017

 

Syed Sammar Abbas, Resident of Unit No.102, Floor 1, Tower A2 Orris Carnation, Sector 85, Gurgaon-122001, Haryana. 

Other Address: R/o A-168 Ashiana Green Hills Neemrana Alwar Rajasthan-301705.

                                      Complainant

Versus

1.      ICICI Lombard General Insurance Company, K-6&K-7+K-12&KB-12, Qutub Plaza, DLF-Phase-1, Gurgaon-122002 through its Authorised Signatory.

2.      IL Health Care, ICICI Lombard General Insurance Company Limited, ICICI Bank, Plot No.12, Financial District, Nanakramgunda, Gachibowli, Hyderabad through its authorised signatory.

                                      Opposite Parties

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Mr. B.M. Bedi, Judicial Member.

                                                                                                         

Argued by:          Mr. Syed Sammar Abbas-complainant in person along with Mr.Madhu Ranjan, Advocate.

                             Mr. Sandeep Suri, Advocate for Opposite Parties.

 

                                                   O R D E R

 

B.M. BEDI, JUDICIAL MEMBER

 

          Syed Sammar Abbas–complainant purchased a Secure Mind Policy (Exhibit C-2) from ICICI Lombard General Insurance Company (for short ‘ICICI Lombard’)-Opposite Party No.1 commencing from 30.09.2013 to 29.09.2018 (wrongly mentioned as from 30.08.2013) with sum assured of Rs.30,000,20/- to secure his home loan liability from the risk of getting diagnosis with certain diseases including Multiple Sclerosis in future.  At the time of obtaining the above said policy, the complainant submitted an application/Proposal Form dated 26.09.2013 (Exhibit C-1) to one Rahul Mailk-the authorised agent of  ICICI Lombard.

2.                It was submitted that the complainant had submitted fitness certificate alongwith the proposal form and specifically mentioned that he suffered severe sudden headache with facial numbness, balance trouble & partial hearing loss in one ear and was a suspected case of Multiple Sclerosis (MS) at Medanta Hospital, Gurgaon. He was also subjected to MRI which was done on 03.05.2013 to 08.05.2013 which showed some lesions. The complainant returned back to normal health after few days of the treatment but the doctors suspected either MS or vasculitis and advised to start interferons treatment for MS but the complainant chose to take second opinion.

3.                The complainant took second opinion at Fortis Escorts Memorial Hospital Department of Neurology escorts by Dr.Rajnish Kumar. Dr. Rajnish briefed the complainant regarding the concept of Dissemination in the Time & Space and Mc Donalds Criteria. Doctor also look CSF Fluid reports and advised the complainant for fresh MRI after 5 to 6 months. Dr. Rajnish did not start any MS medication and said the suspicious and risk of MS could not be confirmed till a new MRI was done. At Fortis Hospital he was told that to be confirmed about MS, there have to be two sudden attacks and since the complainant had suffered only one attack, therefore, it was not a case of confirmed MS.

4.                Complainant again suffered pain on the left side body on 11.07.2013 and was advised not to get nervous and was subjected to MRI whereupon he was issued fitness certificate. The complainant was stated to have specifically mentioned in the proposal form that he was mis-diagnosed of Multiple Sclerosis (MS) and attached fitness certificate issued from Fortis Hospital. However, the complainant has left the column of pre-existing disease as blank and showed in the insurance cover also the said column of pre-existing disease blank. As per the complainant, in the month of May, 2014 he received fatigue and visited to Dr. Rajnish who had also issued fitness certificate and subjected to MRI where he was diagnosed as a case of MS type Relapsing Remitting Multiple Sclerosis (RRMS). The complainant also received treatment from Swai Man Singh Chikitsalya, Jaipur where he was confirmed to be a patient of MS. The complainant approached the ICICI Lombard to pay his home loan which was got insured. However, the ICICI Lombard repudiated the claim. Hence, complaint under Section 17 of the Consumer Protection Act, 1986 was filed.

5.                The opposite parties contested the complaint by filing written version raising plea that the complainant was issued Secure Mind Policy. It was submitted that since the complainant was suffering from pre-existing disease as per the Discharge Summary of Medanta Hospital dated 08.05.2013 where he was diagnosed as a patient of Multiple Sclerosis, a pre-existing disease. Therefore, it being a pre-existing disease, complainant’s claim was rightly repudiated.

6.                In evidence, the complainant himself has appeared as CW-1 and tendered documents Exhibits C-1 to C-8.  The opposite parties did not lead any evidence.

7.                Arguments heard. File perused.

8.                The insurance policy (Exhibit C-2) is on the file. The complainant while appearing as CW-1 admitted that he fell sick and received treatment from Medanta Hospital and was diagnosed as a patient of Multiple Sclerosis (MS) as per record of Medanta Hospital (Exhibit C-3) and was discharged on 08.05.2013. The complainant admitted that he took second opinion dated 07.09.2013 (Exhibit C-4) from Fortis Hospital, Gurgaon. He again received treatment from Swai Man Singh Chikitsalya, Jaipur (Exhibit C-5) where he was diagnosed and confirmed as a case of MS on 04.07.2014. The complainant has referred to his proposal form where the complainant was stated to have disclosed that he was mis-diagnosed with Multiple Sclerosis (MS) and attached a consultation of fitness from other hospital. The hospital treatment record of the complainant from Medanta Hospital is on the file. He also subjected to MRI. Based on MRI report it was diagnosed as a case of Multiple Sclerosis (MS). The complainant remained admitted in Medanta Hospital (Exhibit C-3) from 03.05.2013 to 08.05.2013. He applied for housing loan as well as Secure Mind Insurance Policy and just a few days before taking the Secure Mind Policy, he procured a certificate of fitness from other hospital and not Medanta. He is purported to have obtained a certificate from Fortis Hospital of his fitness. If the complainant was sure that he was not suffering from disease and was mis-diagnosed, more particularly when he left Medanta Hospital to have second opinion, which he did not take, what necessitated to obtain second opinion just a few days before raising housing loan and purchase the Secure Mind Policy after more than four months leaves a question mark. Thus, coupled with the fact that at Fortis Hospital he had only gone to obtain certificate without any admission or any test being carried out.

9.                There is another fact that he has obtained fitness certificate and went to Fortis Hospital on 11.07.2013 where he was advised MRI but did not get it done. He again visited Fortis Hospital on 18.07.2013 in OPD and was again advised MRI. MRI report is on the file from Unique Diagnosis & Research Centre on being referred by Fortis Hospital. This report is dated 18.07.2013 and was again found to be suffering from Multiple Sclerosis (MS). The opinion given is reproduced below:-

“Opinion: MR Features are s/o? vasculitis?? multiple sclerosis as described.”

10.              There is again MRI report of Unique Diagnosis & Research Centre dated 30.05.2014 (Annexure R-10). It is again mentioned to be a case of Multiple Sclerosis. Even as per the treatment record (Exhibit C-5) of Swai Man Singh Chikitsalya, Jaipur, the insured was found a case of Multiple Sclerosis. Therefore, the case of the complainant that he was mis-diagnosed a case of MS  during his admission from 03.05.2013 to 08.05.2013 at Medanta by obtaining fitness certificate dated 7.9.2013 despite MRI dated 18.07.2013 on the prescription of Fortis Hospital, raises a doubt about the fitness certificate produced by the complainant for the purpose of obtaining the policy. That besides the certificate dated 07.09.2014 has not been got authenticated from any person. When it has been described to be a case of Multiple Sclerosis during the admission in hospital on 18.5.2013 and again on 30.5.2014 by Medanta Hospital followed by Swai Man Singh Chikitsalya, Jaipur on 4.7.2014, he was certainly a case of Multiple Sclerosis before the purchase of the policy.

11.              Next question to be seen as to whether the said disease was covered for the purpose of raising housing loan, the insurance policy (Exhibit C-2) is on the file. In the insurance policy, there is coverage of certain diseases under the heading “Major Medical Illness & Procedures”. In the column of Coverage, list of covered illnesses has been given.  However, there is exclusion in the event of pre-existing diseases. Thus, when certainly complainant was a case of pre-existing M.S., therefore, his case fell under exclusion clause.  

12.              In view of the above evidence it is established that the complainant suffered from the disease which was falling under exclusion clause and therefore the complainant is not entitled for any compensation. Hence, the complaint is dismissed being devoid of merits.

 

Announced: 27.01.2017

(B.M. Bedi) Judicial Member

(Nawab Singh) President

 

CL