District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 127/2021.
Date of Institution:05.03.2021.
Date of Order: 21.02.2023.
Satish Kumar S/o Om Parkash, Village Sotai, Holi Patti, Near BSNL Tower, Fatehpur, Ballabgarh, Distt. Faridabad.
…….Complainant……..
Versus
M/s. Cholamandalam MS General Insurance Company Ltad., Samyak Tower, Plot NO. 39, 2nd floor, Opp. – Pillar NO. 120, Pusa Road, New Delhi9 (Service may also be effected through branch office).
…Opposite party……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. V.S.Badgujar, counsel for the complainant.
Sh. O.P.Gaur, counsel for opposite party
ORDER:
The facts in brief of the complaint are that at the inducement and instigation by the agent of opposite party, the complainant took medical claim insurance bearing membership No. A5479377A and prior to making the membership, the opposite party made the entire formalities and also the opposite party got medically checked the complainant through its designated centre. After finding that there was no old disease and after having full satisfaction by the side of opposite party, the complainant was made a member of the opposite party under mediclaim insurance. All of a sudden, complainant fell from stairs on 14.09.2020 and resultantly complainant sustained various injuries. The complainant suffered from acute pain even after taking pain killer and thereafter he got done his MRI from Focus Diagnostic and thereafter the complainant got admitted on 17.09.2020 in Sarvodaya Hospital, Faridabad. The complainant was treated by the Orthopedics and Spine Surgery department of the above said hospital and the admission was registered bearing No. IP218717 and various investigations were conducted by the treating doctor. Finally, the complainant was advised to undergo surgery i.e. Fracture vertebrae for surgical management. The complainant being medically insured with the opposite party, the above hospital sent the details of the complainant alongwith medical and investigation documents to the opposite party for the approval of insurance money. Accordingly, the opposite party vide letter dated 18.09.2020 issued cashless authorization letter to the hospital approving part payment of Rs.1.00 lakh. Thereafter, the complainant went under surgery and he was discharged on 24.09.2020 and the complainant had paid Rs.2,56,907/- by credit card of HDFC bank and prior to that the complainant had also deposited Rs.10,000/-. After discharge, the complainant sent the entire records, bills, discharge slips, investigation reports alongwith claim form on 13.10.2020, which were got received and acknowledged by the opposite party. But the opposite party without accepting, considering and without assigning any reason, have sent back and returned all the above documents to the complainant. The complainant was so shocked, astonished and traumatized after seeing that all the documents had been returned back as it was and no remarks letters had been sent by the opposite party. The above document shad been sent back by the opposite party deliberately and intentionally while avoiding their liability of making the above payment. The complainant sent legal notice dated 24.12.2020 through his counsel to the opposite party but all in vain. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) make the payment of Rs.2,66,907/- with interest @ 24% p.a. till the actual realization of the amount.
b) pay Rs. 2,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 21,000 /-as litigation expenses.
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that the insured had availed first time, the Group Health Insurance Policy bearing NO. 2876/00036595/000005/000/00 valid from 09.12.2019 to 087,12,2020 for covering the family for the sum insured of Rs.7,50,000/-. It was submitted that the complainant had suppressed and concealed the true, material and vital facts and information in lodging the present complaint before this Hon’ble Commission and thus had not come with his clean hands. It was submitted that the complainant being of 71 years old lodged claim with the insurance company in respect of his hospitalization vide claim form received by the insurance company on 13.10.2020 and attaching therewith discharge summary for the period 20.09.2020 to 24.09.2020 issued by Sarvodaya Hospital & Research Centre, Sector-8, Faridabad , for the reimbursement of medical expenses of Rs.2,66,907/-. As per the discharge summary, the complainant attended the hospital with the complaint of sever pain in lower back for 7 days, difficulty in walking and a history of all from stair on 14.09.2020. however, the complainant was finally diagnosed as a case of fracture of D-11 “Vertebra”, for which the hospital conducted the procedure “Posterior Spinal Fixation with screw fixation”. It was submitted that the insurance company thoroughly and carefully investigated into the subject claim and observed that the complainant was suffering from diabetic since 5 years, as per the history record in the submitted documents, which was not disclosed by the insured at the time of inception of the medi insurance policy. It was further submitted that the insured had intentionally, willfully, purposely and knowing violated, infringed and breached the terms and conditions of the medi insurance policy inter alia General condition: 4.1. Accordingly, the insurance company arrived at its decision in treating the subject claim as “Repudiated” vide its letter dated 01.12.2020 strictly within the scope of the terms and conditions of the medi insurance policy, which decision cannot be termed unconscionable at all. Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite party– MS General Insurance Company Ltd., with the prayer to: a) make the payment of Rs.2,66,907/- with interest @ 24% p.a. till the actual realization of the amount. b) pay Rs. 2,00,000/- as compensation for causing mental agony and harassment . c) pay Rs. 21,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Satish Kumar, .C-1 – discharge summary, C2 – receipt, C3 – receipt of payment and refund,, C4 – receipt of Rs.10,000/-, C-5 – Tax invoice, C-6 – Summary bill of supply, C-8 – Bill cum receipt, C-8 - OPD card of Aman Hospital, C-9 to C-12– Sales summary, C-13 – Bill of supply, C-14 – MRI Dorsolumbar Spine,, C-15 to 16– tests, C-17 – certificate issued by Sarvodaya Hospital & Research Center, C-18 - note of Dr. Ashish Tomar dated 25.09.2020, C-19 - note of Dr. Ashish Tomar, Consultant Ortho and Spine Surgery, C-20 – C22- reports, C-23 - Details of TPA (Notice or communication to be given in respect of claims), C-24 to C-29– tests, C-30 - insurance policy, Ex.C-31 – receipt, C-32 – Insurance policy, C-33 – Group Health Insurance- Certificate wordings,, C-34 - Group Health Insurance Certificate of Insurance, C-35 – E-Card, C-36 - Additional Information Request letter to the hospital,, C-37 – Cashless Authorization letter to the hospital, C-38 – terms and conditions, C-39 – Identity card, C-40 - Claim Form – Part B, C-42 -Claim Form – Part A, C-43 – letter,,C-44 – postal receipt,, C-45 – legal notice.
On the other hand counsel for the opposite party strongly agitated and
opposed. As per the evidence of the opposite party Ex.RW1/A – affidavit of Shri Sujeet Kumar Sahu, Deputy Manager (Legal) M/s. Cholamandalam MS General Insurance Company Ltd., Office at: Samyak Tower 2nd floor, plot No.39, Opposite Metro Pillar NO. 120, Pusa Raod, Karol Bagh, New Delhi, Annx.O/1 – insurance policy with terms & condition, Annx.O/2 – Claim form-Part A, Annx.O/3 – Discharge summary, Annx.O/4 – bill dated 25.09.2020, Annx.O/5 – Repudiation letter dated 01.12.2020.
6. In this case, the complainant has obtained the insurance policy for the period 09.12.2019 to 08.12.2020 covering his family. All of a sudden, the complainant himself fell from stairs on 14.09.2020 resulting into suffering of injuries on his person. Thereafter, he got MRI conducted from M/s. Focus Diagnostic Centre, however, admitted on 17.09.2020 in Sarvodaya Hospital, Faridabad. The complainant was advised to undergo surgery of “fracture Vertebra”. Since the complainant was insured with the insurance company, so the hospital sent all the details and documents to the insurance company for reimbursement of medi expenses, for which cashless authorization vide letter dated 18.09.2020 was issued. In furtherance of the treatment, the complainant was discharged from the hospital on 24.09.2020 for which the hospital raised a bill of Rs.2,56,907 /- and the same was paid via bank credit card. Opposite party repudiated the claim of the complainant vide letter dated 01.12.2020 vide Annx.O/5 on the ground that the insured was suffering from Diabetic since 5 years as per the history recorded in the submitted documents, this information was not disclosed in the proposal form while proposing for insurance. In view of this non –disclosure of material information, the contract of insurance becomes void and no claim was payable under this policy.
7. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed. Opposite party is directed to process the claim of the complainant as per the terms and conditions of the policy within 30 days from the date of receipt of the copy of order and pay the due amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint till its realization. The opposite party is also directed to pay Rs.2200/- as compensation on account of mental tension, agony and harassment alongwith Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 21.02.2023 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
