DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi- 110016
Case No.268/2011
Sh. Saurabh Patel
S/o Shri J.P, Patel
R/o H.No.90/63, Tulsi Nagar
Bhopal (Madhya Pradesh) ….Complainant
VERSUS
Medi Assist Private Ltd.
F-2, Kailash Plaza
H-252, Sant Nagar
New Delhi-110065.
Reliance General Insurance Co. Ltd.
19, Reliance Centre
Walchand Hirachand Marg
Ballard Estate
Mumbai ….Opposite Parties
Date of Institution : 04.08.2011
Date of Order : 11.07.2022
Coram:
Ms. Monika A Srivastava, President
Ms. Kiran Kaushal, Member
Sh. U.K. Tyagi, Member
ORDER
Member: Sh. U.K. Tyagi
The complainant has requested to pass an order directing the Medi Asst. Private Ltd. and Reliance General Insurance Co. Ltd. (hereinafter referred to as OP1 & 2 respectively) (i) to pay the sum of Rs.69,558/- spent on treatment; (ii) interest @12% w.e.f. 10.12.2009 to 31.5.2011 for 17 months; (iii) to pay a sum of Rs.50,000/- towards mental harassment and an amount of Rs.22,000/- as litigation charges etc. etc.
Brief facts of the case are as under:-
The complainant took medical insurance policy from OP-2 for the insured sum of Rs. 2 Lac for the currency of the period from 04.11.2009 to 03.11.2010 and paid an amount of Rs.2,723/- as premium. The complainant suffered fracture on his right knee known as ACL tear on 8.12.2009. The complainant got MRI screening of his right knee from Ganesh Diagnostic & Imaging Centre Pvt. Ltd. Rohini, Delhi. The complainant approached Sehgal Nursing Home and Neurological Research Institute – B-21-22 Kailash Colony, New Delhi. He remained in Hospital from 9.12.2009 to 10.12.2009 for surgery.
The complainant submitted the claim of Rs.69,558/- to OP-2 alongwith requisite documents. Despite follow up to OP-1 & OP-2, no response was received. The complainant also got legal notice served on the OP-1 & 2. Hence there is deficiency in service on the part of OP-1& 2. Hence the complaint.
OP-2, on the other hand, filed reply inter-alia raising preliminary objections. It is observed that the complainant had injury one day before the admission in the Hospital on 9.12.2009 meaning thereby injury was caused on 8.12.2009. But as per Jaipur Gold Hospital Consultation, he had injury on 7.12.2009. A copy of private OPD of Dr. Shitiz Kumar on 7.12.2009 of Jaipur Golden is attached herewith as Annexure R-1. Where it seems that doctor has tampered with dates of visit to hospital from 09.12.2009 to 07.12.2009 at point ‘X’. It is also noted that Dr. Ashok Raj Gopal, Chairman of Medenta and Sehgal Nursing Home on 07.12.2009 has referred the case of complainant for operation at 6.15 am on 9.12.2009. The patient was recommended for operation on 07.02.2009 itself without the MRI. The MRI test conducted on 08.12.2009. It was averred that the injury was old one and it was predecided to operate the same. A copy of the consultation slip of Dr. Ashok Raj Gopal dated 07.12.2009 is attached herewith as annexure R1/2. The OP further averred that it was in their know and were just waiting of 30 days of policy inception period to expire. The test of MRI on 8.12.2009 and advice of the doctor for operation on 9.12.2009 shows that doctor was well aware about the ailment and does not require investigation.
During investigation, it was discovered that the father of insured is also an orthopaedic surgeon in JP Hospital, Bhopal. At this stage, OP alleged that why the father will not object for the operation without MRI and thus it strengthens the view that the ailment was pre-existing and treatment is delayed to get the same covered under insurance policy. It was also stated that the policy inception was of 04.11.2009 and father of insured being a doctor, is aware of the fact that no such treatment is covered within 30 days of the inception of the policy. The OP also stated that the insured is studying in IIT Roorkee, and belongs to Bhopal and is getting treatment in Delhi. It requires investigation and can be arrived at correct decision by lot of evidences and witnesses. Therefore, requested for transfer of case in Civil Courts for ascertaining the fact.
OP-2 and complainant has filed evidence in affidavit: Written statement is on record so is rejoinder. OP-2 did not file argument despite many opportunities granted for filing the written arguments. Oral arguments were heard and concluded.
This Commission has gone into the material placed on record. Due consideration was given to the arguments as well. It is noted that the OP-2 had tried to prove that the insured was having the ailment i.e. ACL at the time of purchase of the policy and same was concealed while filling up the proposal form. The contract of the insurance is based upon the doctrine of uber rima fides i.e. of the utmost Good Faith and all the details to be filled in the proposal form, should be furnished appropriately, honestly and disclosing all material facts within the knowledge of the insured so as to enable the insurance company to assess the loss in fair and just manner. As is discussed above, the treating doctor at Medenta & Sehgal Nursing Homes, fixed the date of operation for 09.12.2009, on 07.12.2009. So much so, the MRI test was conducted on 08.12.2009 whereas MRI test to ascertain the exact location of ACL, should have been taken much before 07.12.2009 when the expert doctor was considering for operation. Such situations are unlikely in the day to day life. It is also noted that the complainant had not controverted these specific narrations in their evidence or rejoinder or elsewhere.
In view of the above mentioned facts and circumstances in this case, this Commission is of the considered view that the OP has proved his case with evidence whereas complainant could not provide evidences to contradict the material of OP. Hence, the complaint fails and his request accordingly is rejected.
No order to the costs.
File be consigned to the record room after giving copy of the order to the parties. Order be uploaded on the website.
