Per Mr.B.S.Wasekar, Hon’ble President

1)                The present complaint has been filed by the complainant u/s 12 of the Consumer Protection Act, 1986. According to the complainant, he had taken healthcare policy for Rs.3 Lakhs for the period from 1^st August, 2010 to 31^st July, 2012 for himself and for his wife.  His wife Rajrani S.Agarwal was hospitalized on 5^th June, 2011 at Chembur in L.C.Manek’s Polyclinic & Nursing Home.  From their, she was transferred to Surana Sethia Hospital and Research Centre, Chembur on 7^th June, 2011 for further treatment.  She was discharged from the hospital on 13^th June, 2011.  The complainant submitted claim to the opponent but the opponent repudiated it vide letter dated 29^th August, 2011.  He had also requested the opponent to settle the claim for Rs.2,90,040/-.  The complainant submitted duplicate discharge card and letter from the Surana Sethia Hospital and Research Centre.  Still, the opponent cancelled policy and return the cheque for Rs.26,972/- vide letter dated 9^th November, 2011.  Inspite of several requests, the opponent refused to settle the claim. Therefore, the complainant has filed this claim for Rs.2,90,040/- with interest and expenses of Rs.10,000/-.  He has also claimed compensation of Rs.50,000/- for mental agony.

2)                The opponent appeared and filed written statement.  It is admitted that policy was taken. The papers submitted by the complainant were securitized and it was found that the complainant had deliberately concealed the existing ailment of insured person therefore the policy was null and void.  The claim was submitted for treatment of pre existing disease which was not covered under the policy.  As per the medical papers submitted by the complainant, the insured took treatment for the seven years old ailment.  Such pre existing disease is not covered under the policy therefore the complainant is not entitled for the claim.

3)                After hearing both the parties and after going through the record following points arise for our consideration

POINTS

REASONS

4) As to Point No.1 & 2 :- The policy is not disputed.  The complainant has produced copy of policy on record.  On perusal of it, there was no pre existing illness at the time of policy.  The complainant has produced copies of medical case papers from L.C.Manek’s Polyclinic and Nursing Home and also from Surana Sethia Hospital and Research Centre.  According to the complainant, who is the husband of patient, the doctor has wrongly written the history of illness for seven to eight years.  According to him he has brought duplicate discharge card showing history of illness for five-six months.  Thus, admittedly, as per the history of medical case papers, the disease was pre existing since seven to eight years.  According to the complainant, this history of seven to eight years illness was wrongly written by the doctor.  The complainant has not produced affidavit from the said doctor who has written wrong history.  In natural course, history of illness will be disclosed by the patient himself.  Patient was Rajrani, wife of the complainant and not the complainant himself. There is no affidavit from Rajrani to show that she told wrong history to the doctor in hospital.  The complainant has produced one letter from Surana Sethia Hospital and Research Centre saying that the history for seven-eight years was wrongly written it is five to six months.  It is not clear whether this letter was issued by the same doctor who has taken the history from the patient in the hospital before starting the treatment. It was necessary for the complainant to submit affidavit of the said doctor showing the reason for writing wrong history in the medical case papers as treatment would have been different for chronic disease.  Even if, it is presumed that history was wrongly mentioned in Surana Sethia Hospital and Research Centre still the question arise why the history was mentioned in the earlier hospital i.e. L.C.Manek’s Polyclinic showing the history for five to six years. It is surprising that in the xerox copy of medical case papers produced by the complainant, it is apparently seen that the illness is since five to six years.  There is overwriting on the word ‘years’ converting it to ‘month’. The complainant was directed to produce the original for our perusal but the complainant could not produce it.  There is also copy of Initial Assessment Sheet from Surana Sethia Hospital and Research Centre produced by the complainant. It shows past history of hypertension and diabetes which exist since seven-eight years. There is over writing on the word ‘years’ converting to ‘month’. Thus, as per the history of two hospitals there was pre existing illness at the time of taking policy.  It shows that the complainant has concealed the pre existing illness from the opponent therefore the policy itself is null and void.  The complainant has tried to defraud the opponent as well as to this Forum by producing forged documents. The complainant has not given any explanation for producing forged document before this Forum. Therefore, the complaint deserves to be dismissed with compensatory cost.  Hence, we pass the following order.

ORDER

1. Complaint stands dismissed with compensatory cost of Rs.10,000/- to be paid by the complainant to the opponent within a period of one month from today.
2. Copies of this order be sent to the parties free of cost.

Pronounced on 1^st August, 2014