BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.300 of 2015
Date of Instt. 15.07.2015
Date of Decision :04.05.2016
Nirmal Singh aged about 64 years son of Surjan Singh R/o Village Yusufpur Darewal Sub Tehsil Lohian Tehsil Shahkot District Jalandhar.
..........Complainant
Versus
1. Medi Assist India TPA Pvt Ltd., B-20, Sector-2 near Sector-15 Metro Station, Opp.HCL Comnet Noida, UP-201301 through its Managing Director.
2. Medi Assist India TPA Pvt Ltd., SCO-61, 2nd Floor, Phase-7, Mohali, Punjab-160062 through its Branch Manager/Regional Manager.
3. The Oriental Insurance Company Limited., Head Office:-A25/27, Asif Ali Road New Delhi, branch office:- SCO-50, PUDA Complex, Opp.Tehsil Complex, Jalandhar through its Branch Manager/ Divisional Manager.
.........Opposite parties
Complaint Under Section 12 of the Consumer Protection Act.
Before: S. Bhupinder Singh (President)
Ms. Jyotsna Thatai (Member)
Sh.Parminder Sharma (Member)
Present: Sh.GS Jhand Adv., counsel for the complainant.
Sh.Birjesh Bakshi Adv., counsel for the OP No.3.
OPs No.1 & 2 exparte.
Order
Bhupinder Singh (President)
1. The complainant has filed the present complaint under section 12 of the Consumer Protection Act against the opposite parties on the averments that complainant got mediclaim insurance policy bearing No.233108/48/2015/812 dated 16.6.2014 from OP No.3 and they issued card bearing No.5013712493 with sum insured upto Rs.1 Lac for treatment in the notified hospital. The complainant undergone treatment for Dyselectrolytemia/CKD ailment from 12.7.2014 to 15.7.2014 at Mukat Hospital and Heart Institute, Sector 34-A, Chadigarh which is a notified hospital. The complainant paid Rs.18,532/- towards his treatment to the aforesaid hospital. The complainant approached the OP for the claim as aforesaid hospital authorities submitted the claim form alongwith relevant documents to the insurance company i.e. OP No.3 but the OP No.3 did not decide the claim case of the complainant. The complainant also served legal notice upon the OPs but they did not settle the claim of the complainant. On such averments, the complainant has prayed for directing the OPs to pay Rs.18,532/- on account of medical expenses incurred by the complainant for his treatment. He has also claimed compensation and litigation expenses.
2. Upon notice OP No.3 appeared through counsel and filed written statement pleading that from the perusal of medical certificate issued by treating doctor Dr.Rajiv Gupta, it was found that patient Nirmal Singh insured was diagnosed for CKD, DM-II, HTN. Patient was complaining of Dysectrolytemia, vomiting for last 2/3 days. In the column of past history with duration of aliment it was mentioned that the complainant suffered from CKD for last seven years and DM type-II, HTN(Hypertension) for 4 years and in discharge summary it was mentioned that he was on regular treatment for the above and the present ailment is complication of pre-existing ailment of CKD, HTN, DM type-II. The complainant was suffering from pre-existing disease prior to the taking of the policy but the complainant did not disclose these details of his health condition. So, the complainant got the policy from the OP by way of concealment of facts. As per clause 4.2 of the terms and conditions of the policy, the expenses on treatment of certain diseases/ailment for the specified period are not payable if contracted/manifested during currency of the policy. As per exclusion clause 4.1 for pre-existing condition, the claim is not payable. So, the claim of the complainant is not maintainable and repudiated by the OP No.3 under the policy terms and conditions. OP No.3 denied other material averments of the complainant.
3. Notice of this complaint was given to the OP No.1 & 2 but nobody has turn-up despite service and as such they were proceeded against exparte.
4. In support of his complaint, complainant has tendered into evidence affidavit Ex.CA alongwith copies of documents Ex.C1 to Ex.C16 and closed his evidence.
5. On the other hand, learned counsel for opposite party No.3 has tendered affidavit Ex.OA alongwith copies of documents Ex.O1 to Ex.O3 and closed the evidence.
6. We have heard the Ld. counsel for the parties, minutely gone through the record and have appreciated the evidence produced on record by both the parties with the valuable assistance of Ld. counsels for the parties.
7. From the record i.e. pleadings of the parties and the evidence produced on record by both the parties, it is clear that complainant got mediclaim insurance policy bearing No.233108/48/ 2015/812 dated 16.6.2014 from OP No.3 and they issued card bearing No.5013712493 with sum insured upto Rs.1 Lac for treatment in the notified hospitals. The complainant underwent treatment for Dyselectrolytemia/CKD ailment from 12.7.2014 to 15.7.2014 at Mukat Hospital and Heart Institute, Sector 34-A, Chandigarh which is a notified hospital. The complainant paid Rs.18,532/- towards his treatment to the aforesaid hospital. The complainant approached the OP for the claim as aforesaid hospital authorities submitted the claim form alongwith relevant documents to the insurance company i.e. OP No.3 but the OP did not decide the claim case of the complainant. The complainant also served legal notice dated 16.6.2015 Ex.C12 upon the OPs through registered post, postal receipt which are Ex.C13 to Ex.C16 but inspite of that the OP did not settle the claim of the complainant. The learned counsel for the complainant submitted that all this amounts to deficiency in service on the part of the OPs qua the complainant.
8. Whereas, the case of the OP No.3 is that from the perusal of medical certificate issued by treating Dr.Rajiv Gupta, it was found that patient Nirmal Singh insured was diagnosed for CKD, DM-II, HTN. Patient was complaining of Dysectrolytemia, vomiting for last 2/3 days. In the column of past history with duration of aliment it was mentioned that the complainant suffered from CKD for seven years and DM type-II, HTN(Hypertension) for 4 years and in discharge summary it was mentioned that he was on regular treatment for the above and the present ailment is complication of pre-existing ailment of CKD, HTN, DM type-II. Therefore, the complainant was suffering from pre-existing disease prior to the taking of the policy but the complainant did not disclose these details of his health condition. So, the complainant got the policy from the OP by way of concealment of facts. Further, as per clause 4.2 of the terms and conditions of the policy, the expenses on treatment of certain diseases/ailment for the specified period are not payable if contracted/manifested during currency of the policy. As per exclusion clause 4.1 for pre-existing condition, the claim is not payable. So, the claim of the complainant is not maintainable and repudiated by the OP No.3 under the policy terms and conditions The learned counsel for the OP No.3 submitted that there is no deficiency in service on the part of the OP No.3 qua the complainant.
9. From the entire above discussion, we have come to the conclusion that complainant obtained mediclaim insurance policy Ex.C1 from OP on 16.6.2014 with sum insured Rs.1 Lac and he was issued card of Oriental Bank Mediclaim Policy Ex.C2 by OP No.3. During the policy period, the complainant has undergone treatment for Dysectrolytemia/CKD ailment from 12.7.2014 to 15.7.2014 at Mukat Hospital and Heart Institute, Sector 34-A, Chandigarh which is a notified hospital in the list of OP No.3 and the complainant paid bill of Rs.18,532/- to the aforesaid hospital authorities. The bills in this regard are Ex.C7 to Ex.C9. The claim was lodged with the OP No.3 by the aforesaid hospital authorities vide claim form Ex.O2. The OP No.3 got investigated the matter through its TPA OPs NO.1 & 2 but the OP did not settle the claim of the complainant for more than one year and the complainant has to file the present complaint on 14.7.2015. The OP could not produce any repudiation letter. However, counsel for the OP No3 submitted that as per the history of the complainant recorded in the medical certificate given by the treating doctor of patient Nirmal Singh Ex.C4/Ex.O1, in the past history column of patient Nirmal Singh, it has been mentioned that the patient has been suffering from CKD for last seven years and DM type-II, Hypertension for 4 years. The OP submitted that these facts were not disclosed by the complainant to the insurance company at the time of taking of the policy. So, the complainant has taken insurance policy from OP No.3 by concealment of facts. So, the claim of the complainant is not maintainable under the exclusion clause 4.1 of the terms and conditions of the policy.
10. Here in this case, the OP did not produce any proposal form filled in and signed by the complainant/insured for taking insurance policy from the OP. The OP intentionally withheld the proposal form nor they could put forwarded any explanation for not producing the same. So, it can not be presumed whether the complainant has concealed any facts while submitting the proposal form. Further, the OP has produced only medical certificate of the treating doctor of the patient Ex.O1 which was also produced by the complainant/insured himself Ex.C4, in which only past history of the patient has been mentioned as CKD from seven years and DM type-II, Hypertension for 4 years but the OP could not produce any past medical record of the complainant to prove that the complainant was taking medicine for the treatment of aforesaid diseases or whether he had knowledge about the aforesaid diseases at the time of taking of policy from the OP. Further, OP could not examine any medical practitioner or doctor who medically treated the complainant for any of the aforesaid diseases. It has been held by Hon'ble National Commission in case United India Insurance Company Limited Vs. Anumolu Rama Krishan, 2012(III) CPJ 44 (NC) that onus is on the insurance company to prove that insured was suffering from aforesaid diseases by producing medical record or the affidavit of the doctor who treated the insured for the aforesaid diseases prior to the taking of the policy by the insured from the insurance company. The Hon'ble National Commission further held that person suffering from silent diseases may not even be aware until condition aggravates and overt symptoms appear.
11. It has been held by Hon'ble National Commission in case Life Insurance Corporation of India & Anr Vs Naseem Bano, 2012(III) CPJ 208 (NC) that bed-head ticket can not be the conclusive proof. There is no piece of evidence which may show that prior to filling-up of policy form, record of any hospital/slips of doctors, any prescriptions showing the name of the medicines which deceased must be taken, saw the light of the day.
12. Similar are the facts of the present case. Moreover, the OP No.3 has intentionally withheld the proposal form submitted by the complainant to the OP for taking the insurance policy to prove that the complainant has concealed the aforesaid facts in the proposal form. Moreover, the OP has only produced certificate of treating doctor Ex.O1/Ex.C4 in which only past history of the complainant has been mentioned without any medical proof. Even the OP did not file affidavit of this treating Dr.Rajiv Gupta to prove who disclosed this past history of the patient or from which source he gathered this past history of the patient. Resultantly, we hold that OP No.3 is not justified in withholding the claim of the complainant regarding his treatment to the tune of Rs.18532/-. Rather OP No.3 is in deficiency of service towards the complainant as they failed to settle/decide the claim case of the complainant for more than one year.
12. Resultantly, we allow the complaint with cost and OP No.3 is directed to pay this amount of Rs.18532/- to the complainant within one month from the date of receipt of copy of this order failing which OP No.3 shall be liable to pay interest @Rs.9% per annum from the date of filing of the complaint till the payment is made to the complainant. The OP No.3 is also directed to pay Rs.2000/- as cost of litigation expenses to the complainant. Copies of the order be sent to the parties free of costs under rules. File be consigned to the record room.
Dated Parminder Sharma Jyotsna Thatai Bhupinder Singh
04.05.2016 Member Member President
