THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR
Consumer Complaint No. 505 of 2014
Date of Institution : 16.9.2014
Date of Decision : 10.08.2015
Sh. Prem Nath Mahajan age about 62 years S/o Sh. Bansi Lal R/o H.No. 2602-A, Gali No.1, Tehsilpura,Amritsar
...Complainant
Vs.
National Insurance Co.Ltd., having its branch office at Batala Road, Amritsar through its Divisional Officer
....Opp.party
Complaint under section 12/13 of the Consumer Protection Act, 1986
Present : For the complainant : Sh. Vikram Puri,Advocate
For the opposite party : Sh.Sandeep Singh Randhawa,Advocate
Quorum : Sh. Bhupinder Singh, President ,Ms. Kulwant Bajwa,Member &
Sh.Anoop Sharma,Member
Order dictated by :-
Bhupinder Singh, President
1 Present complaint has been filed by Sh. Prem Nath Mahajan under the
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provisions of the Consumer Protection Act alleging therein that he had obtaining mediclaim policies from the opposite party since 2011 and lastly he obtained mediclaim policy bearing No. 404402/48/13/8500000960 from the opposite party for the period from 16.8.2013 to 15.8.2014 covering the complainant himself, his wife Mrs. Neena Gupta and one child by paying premium of Rs. 4213/- with sum assured Rs. 3,00,000/-. Complainant has alleged that before issuing the mediclaim policy , medical check up of the complainant and his spouse was got conducted by the opposite party. During the validity of the policy period, the complainant developed some problem in his chest and he was admitted in Fortis Hospital on 1.5.2014 at 3.18 a.m and on the same day i.e. on 1.5.2014 he was discharged at 12.50 p.m and incurred an expenditure of Rs. 21000/- on his treatment. The complainant again developed some problem in his heart and again he was admitted in Fortis Hospital on 5.5.2011 and after doing Angiography, the concerned doctor of Fortis Hospital recommended for heart by-pass surgery and the same was conducted on the complainant on 12.5.20145 and complainant was discharged on 18.5.29014 and on his treatment complainant incurred an amount of Rs. 2,64,000/-. After discharge from the hospital, complainant lodged claim with the opposite party and provided all the relevant documents to the opposite party. But the opposite party vide letter dated 22.8.2014 repudiated the claim of the
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complainant on the ground that complainant had been suffering from diabetes mellitus for 3-4 years and hypertension for 5-6 years which are pre-existing diseases. Alleging the same to be deficiency in service complaint was filed seeking directions to the opposite party to pay the claim amount of Rs. 2,64,000/- alongwith interest @ 18% p.a. Compensation of Rs. 30000/- alongwith litigation expenses were also demanded.
2. On notice, opposite party appeared and filed written version in which it was submitted that as per terms and conditions of the policy as per clause 4.1 all pre-existing diseases when the cover incepts for the first time until 48 months of continuous coverage has elapsed. It was submitted that the complainant is known case of diabetes mellitus for the last 3-4 years and hypertension for the last 5-6 years as per the reply to the query by Dr.H.P.Singh, consultant Incharge of Fortis Hospital and as such the disease falls in the category of pre-existing disease before the commencement of the policy and as such the complainant is not entitled for any compensation . It was submitted that complainant has concealed the facts regarding pre-existing disease, as such the claim has rightly been repudiated and there is no deficiency of service.
3. Complainant tendered into evidence his affidavit Ex.C-1 and C-2, copy of repudiation letter dated 22.8.2014 Ex.C-3, copy of policy Ex.C-4, copy of identity
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card issued by the opposite party Ex.C-5, copies of bills Ex.C-6 and C-7.
4. Opposite party tendered affidavit of Sh.M.S.Bhatia,Divisional Manager Ex.OP1, copy of policy Ex.OP2, copy of terms of the policy Ex.OP3, copy of letter dated 6.5.2014 Ex.OP4, copy of letter dated 22.8.2014 Ex.OP5, copy of letter dated 31.8.2014 Ex.OP6, copy of letter dated 21.5.2014 Ex.OP7.
5. We have carefully gone through the pleadings of the parties, arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for the parties.
6. From the record i.e. pleadings of the parties and the evidence produced on record by both the parties , it is clear that complainant obtained mediclaim policy bearing No. 404402/48/13/8500000960 from the opposite party for the period from 16.8.2013 to 15.8.2014 covering the complainant himself, his wife Mrs. Neena Gupta and one child with sum assured Rs. 3 lacs. The complainant further alleges that he had been obtaining mediclaim policy from the opposite party since 2011 regularly. The complainant developed some problem in the chest and he was admitted in Fortis Hospital, Amritsar on 1.5.2014 at 3.18 a.m and he was discharged on the same day at 12.50 p.m and during this period the complainant incurred Rs. 21000/-. Thereafter the complainant was again admitted in Fortis
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Hospital,Amritsar on 5.5.2014 . After doing Angiography the concerned doctor of Fortis Hospital recommended for heart by-pass surgery of the complainant and he was operated on 12.5.2014 and was discharged from the hospital on 18.5.2014. The complainant incurred an amount of Rs. 2,64,000/- on his treatment. Claim was lodged with the opposite party. But the opposite party repudiated the claim of the complainant vide letter dated 22.8.2014 Ex.C-3 on the ground that complainant was suffering from Diabetes Mellitus for the last 3-4 years and Hypertension for the last 5-6 years. The complainant was never suffering from the diseases prior to the taking of the policy. Ld.counsel for the opposite party submitted that opposite party has wrongly repudiated the claim of the complainant and all this amounts to deficiency of service on the part of the opposite party qua the complainant.
7. Whereas the case of the opposite party is that the complainant has suppressed the material facts from this Forum. The complainant was a known case of Diabetes Mellitus for the last 3-4 years and Hypertension for the last 5-6 years as per the reply to the query by Dr. H.P.Singh, Consultant Incharge of Fortis Hospital. So the disease falls in the category of pre-existing disease before the commencement of the policy. Therefore, the complainant is not entitled to any compensation under the policy. Ld. Counsel for the opposite party submitted that the opposite party has rightly repudiated the claim of the complainant vide letter dated 22.8.2014 Ex.C-3.
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As such there is no deficiency of service on the part of the opposite party qua the complainant.
8. From the entire above discussion, we have come to the conclusion that complainant obtained mediclaim policy bearing No.404402/48/13/8500000960 Ex.OP2 from the opposite party for the period from 16.8.2013 to 15.8.2014 covering the complainant, his wife Mrs.Neena Gupta and one child , with sum assured Rs. 3 lacs. The complainant became ill and he was admitted in Fortis Hospital,Amritsar on 1.5.2014 and was discharged on the same day i.e. 1.5.2014 and he paid Rs. 21306/- to the said hospital vide bill Ex.C-7. The complainant was again admitted in the aforesaid hospital on 5.5.2014 and was recommended heart by-pass surgery. The complainant was operated on 12.5.2014 and was discharged on 18.5.2014 and he spent Rs. 2,42,314/- as per bill of Fortis Hospital Ex.C-6. In all the complainant spent Rs. 2,63,600/-. The claim was lodged by the complainant with the opposite party. But the opposite party repudiated the claim of the complainant vide letter dated 22. 8.2014 Ex.C-3 on the ground that as per the report obtained on the query from Fortis Hospital, Amritsar Ex.OP4, the complainant was a known case of Diabetes Mellitus for the last 3-4 years and Hypertension for the last 5-6 years. Opposite party relied upon the repudiation letter of its TPA India Pvt.Ltdf Ex.OP7 dated 21.5.2014 in which it has been
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mentioned that the case of the complainant is a case of CAD with history of DM and HT. The policy since 2011 as well as on the query reply of Fortis Hospital,Amritsar Ex.OP4 dated 6.5.2014 , all these reports have been given by the hospital as well as TPA on the basis of history of the patient recorded in the treatment record of the complainant. The opposite party did not produce any medical record of the complainant to prove that the complainant was a patient of Diabetes Mellitus as well as Hypertension at the time of taking the policy from the opposite party. Further the opposite party did not examine any doctor or medical practitioner to prove that he has medically treated for these diseases prior to the taking of the policy by the complainant from the opposite party nor the opposite party filed any affidavit of any doctor or medical practitioner to prove that he ever medically treated the complainant for the aforesaid diseases i.e. Diabetes Mellitus as well as Hypertension prior to the taking of the policy by the complainant from the opposite party . So the opposite party was not justified in repudiating the claim of the complainant only on the ground that in the history of the complainant recorded when he was admitted in Fortis Hospital,Amritsar on 1.5.2014 and 5.5.2014 that he was written as a known case of Diabetes Mellitus and Hypertension . It has been held by the Hon'ble National Commission in case New India Assurance Co.Ltd & Anr Vs. Murari Lal Bhusri 2011(III) CPJ 198 (NC) that
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where the Insurance company failed to produce any evidence to show that respondent was aware of any pre-existing disease at the time when insurance policy was taken, opposite party was not justified in repudiating the claim of the complainant on the ground of pre-existing disease. It has been held by the Hon'ble Supreme Court of India in case P.Vankat Naidu Vs. Life Insurance Corporation of India & Anr 2011(3) CPC 350 that where no cogent evidence was produced by the respondent to prove that insured/deceased had concealed any fact about his illness or hospitalization, it was held that no material fact was suppressed by the deceased in this respect. Resultantly we hold that the complainant is entitled to claim under the policy in question from the opposite party.
9. As regards the claim of Rs. 21306/- , the complainant was admitted in the Fortis Hospital, Amritsar on 1.5.2012 and was discharged on the same day and he remained admitted in the hospital only for 9-10 hours, so his hospitalization was less than 24 hours. As such the complainant is not entitled to reimbursement of this amount of Rs. 21306/- of bill Ex.C-7. However, the complainant remained admitted in Fortis Hospital, Amritsar from 5.5.2014 to 18.5.2014 i.e for about 14 days and he spent Rs. 2,42,314/- as per bill of Fortis Hospital,Amritsar Ex.C-6.
10. Resultantly we hold that complainant is entitled to reimbursement of this amount by the opposite party under the policy in question.
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11. Consequently we partly allow this complaint with costs and the opposite party is directed to pay this amount of Rs. 2,42,314/- as per bill of Fortis Hospital,Amritsar Ex.C-6 to the complainant , within one month from the date of receipt of copy of this order ; failing which opposite party shall be liable to pay interest @ 9% p.a on this amount from the date of filing of the complaint till payment is made to the complainant. Opposite party is also directed to pay litigation expenses Rs. 2000/- to the complainant. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
10.08.2015 ( Bhupinder Singh )
President
( Kulwant Kaur Bajwa) (Anoop Sharma)
/R/ Member Member
