Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 258
Instituted on : 09.05.2023
Decided on : 14.10.2023
Krishan Kumar S/o Shivcharan resident of H. No. 6/1. Ward no.21, Gohana Road, Bank Colony, Rohtak.
………..Complainant.
Vs.
- Megma HDI General Insurance co. Ltd., Development House, 24 Park Street, Kolkata-700016 through its Regional Manager.
- Megma HDI General Insurance Co. Ltd., 1st Floor, SCO-37, Sector-14, Gurugram through its Divisional Manager.
……….Opposite parties.
COMPLAINT U/S 35 OF CONSUMER PROTECTION ACT,2019.
BEFORE: SH. NAGENDER SINGH, PRESIDENT.
DR. TRIPTI PANNU, MEMBER.
Present: Sh. YashvirDahiya, Advocate for the complainant.
Sh. Gulshan Chawla, Advocate for the Opposite parties.
ORDER
SH. NAGENDER SINGH KADIAN, PRESIDENT :
1. Brief facts of the case, as per the complainant are he had purchased one Health insurance policy for himself, for his wife and two minor children i.e. for son Deepanshu and daughter Aditi bearing No. P0023100021/6111/100761 which was valid from 24.09.2022 to 23.09.2023 and sum insured of this policy was Rs.5,00,000/-. The complainant had paid the premium of Rs.14,586/- at the time of issuance of the policy. Complainant fell ill with symptoms such as fever, loose stool, pain in abdomen, dizziness and was got admitted to New Max Hospital, Rohtak for treatment from 02.02.2023 to 06.02.2023. The total expenses for treatment amounted to more than Rs.79,194/- which he paid to the hospital. Afterward, he submitted a claim under the health policy with all required documents including bills and discharge summary to the office of opposite party on 4.3.2023 vide claim no.23030701046. However, the claim has not been settled despite repeated requests via emails. On 19.3.2023, the opposite party issued a letter rejecting the claim citing that the claim fell under clause 4.1.1 which allows the policy to be voided in the case of misrepresentation by the policyholder. The complainant disputes this repudiation stating that the opposite party wrongfully denied his claim without fault on his part. On 29.03.2023, the complainant sent a legal notice to the opposite party and requested to pay the claim but in vain. Hence there is deficiency in service on the part of opposite parties. Accordingly it has been prayed that opposite parties may kindly be directed to pay the medical claim amounting to Rs.79,194/- along with @18% p.a interest, to pay Rs.1,00,000/-as compensation for mental tension, financial loss &harassment and Rs.22,000/- towards litigation expensed besides any other relief which this Commission may deemed appropriate.
2. Notice of the present complaint was issued to the opposite parties. The opposite parties appeared and filed their written statement submitting therein that immediately after the complainant submitted medical record and invoices, the opposite party conducted standard investigation. Upon enquiry with the doctor named in the invoices, it was confirmed that the complainant was not treated by that doctor. Further investigation showed that the data of the phone of the complainant indicated presence of complainant in the vicinity of hospital but not within the hospital as claimed. This reveals manipulation and concealment of information leading to the conclusion that the complainant engaged in fraudulent activity. Thus the complainant has breached the policy terms, specifically section 4.1.6 on “Fraud”, which stipulates forfeiture of benefits and premium of the policy. The claim was rightly repudiated by the opposite party on the basis of breach of terms and conditions of the policy on the grounds of fraudulent misrepresentation. It is further submitted that the complainant did not follow the mandatory requirement of notifying the opposite party within the prescribed time frame before and after hospitalization. As per policy, information must be provided within 72 hours before planned hospitalization or within 24 hours of emergency hospitalization. This failure constitutes a breach of policy. The opposite party repudiated the claim on the ground of fraudulent concealment. The complainant provided altered documents and further investigation revealed discrepancies such as: that the treating doctor Rohit Singh Narwal verified that the complainant was not under his care and his identity was misused;the complainant’s phone data indicated movement outside the hospital during the alleged hospitalizationperiod; that medical records including pathology reports were found to be inconsistent with typical hospital practices that complainant was not admitted in the hospital; Laboratory reports were also suspicious that did not match with usual procedure. Therefore it is contented that the claim was rightly been repudiated on the grounds as per the contractual terms 4.1.6 “Fraud”. Further the insurance company is not liable to fulfill the claim based on the fraudulent actions of the complainant. It is prayed that complaint may kindly be dismissed with costs.
3. Learned counsel for the complainant has tendered affidavit Ex. CW1/A, documents Ex. C-1 to Ex.C-35 in his evidence and closed the same on dated 30.11.2023. Learned counsel for the opposite party has tendered affidavit Ex. RW1/1, documents Ex. R-1 to Ex R-7 and closed his evidence on 30.4.2024.
-
-
6. Application(s) pending, if any, stand disposed of in terms of the aforesaid judgment.
7. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
14.10.2024.
................................................
Nagender Singh Kadian, President
………………………………..
TriptiPannu, Member.
