Delhi

East Delhi

CC/1136/2013

ROBERT ANTHONY - Complainant(s)

Versus

NATIONAL INS. - Opp.Party(s)

13 Jul 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

 

C.C. NO. 1136/13

 

Shri Robert Anthony

S/o Late Shri A. Alexander

R/o House No. 8-B/3

Janta Garden, Street No. 3

Pandav Nagar, Patparganj

Delhi – 110 091                                                        ….Complainant

 

Vs.    

 

National Insurance Company Ltd.

Through its AR/Manager/Director

Branch Office : 50, Janpath

New Delhi – 110 001                                                       …Opponent

 

 

Date of Institution: 31.12.2013

Judgement Reserved on: 13.07.2018

Judgement Passed on: 17.07.2018

CORUM:

Sh. Sukhdev Singh (President)

Dr. P.N. Tiwari (Member)

Ms. Harpreet Kaur Charya (Member)

 

Order By: Sh. Sukhdev Singh (President)

 

JUDGEMENT

            This complaint has been filed by Shri Robert Anthony against National Insurance Company Limited (OP) under Section 12 of the Consumer Protection Act, 1986 with allegations of unfair trade practice and deficiency in service. 

2.       The facts in brief are that on the representation of the agent of the National Insurance Company Ltd. (OP) complainant has switched over from the other policy to the mediclaim policy of National Insurance Company in his name in December, 2009 vide policy no. 251100/46/11/8500001236/087263 with medical coverage of          Rs. 2,00,000/- and premium amount of Rs. 6,727/- per annum.  The complainant was regularly paying the premium till November, 2013. 

          It was stated that the complainant was hospitalized on 24.04.2013 and discharged on 29.04.2013 at Sir Ganga Ram Hospital which was on the penal of National Insurance Company Limited (OP), but at the time of approval/bill payment, OP flatly rejected the approval of the hospital for bill amount of Rs. 2,14,000/-.

          It was further stated that the complainant submitted all the required documents with OP within 30 days from the date of discharge and completed all formalities.  He approached the OP and requested to pay the policy coverage amount of Rs. 2,00,000/-, which was already spent by the complainant on his treatment, but OP rejected the claim of the complainant on the ground of Pre-existing Disease.   Thus, the complainant have stated that this amounts to deficiency in service on the part of OP and unfair trade practice.  Hence, he has filed the present complaint and prayed for directions to OP to refund the medical claim policy amount of Rs. 2,00,000/-; compensation of Rs. 50,000/- towards mental agony, pain and harassment; Rs. 20,000/- for deficiency of service and indulging in unfair trade practice and Rs. 25,000/- towards cost of litigation.

3.       In the reply, filed on behalf of National Insurance Company Limited (OP), they have taken various pleas.  It was admitted that OP issued a Health First Floater Policy to the complainant for the period 15.11.2012 to 14.11.2013.

          It was stated that as per discharge summary, the complainant had undergone surgery for Right Frontal Meningioma in 2005 and he suppressed the material facts at the time of taking the policy first time in 2009.  Hence, the claim of the complainant was repudiated vide letter dated 10.08.2013 by Dedicated Health Services, TPA, on the ground of misrepresentation.  Other facts have also been denied.       

4.       Rejoinder to the WS of OP was filed by the complainant where the contents of the WS have been denied and has reaffirmed the averments of his complaint. 

5.       In support of its case, the complainant have examined himself.  He has deposed on affidavit.  He has narrated the facts which have been stated in the complaint.  He has got exhibited documents such as copy of receipt of premium amount and cover note of the policy (Ex.CW-1/1 and 1/2), copy of repudiation letter (Ex.CW-1/3) and copy of bills for          Rs. 2,14,000/- (Ex.CW-1/4).

          In defence, OP have examined Shri Rajneesh Kumar, Admn. Officer of OP, who has also deposed on affidavit.  He has also narrated the facts which have been stated in the WS. 

6.       We have heard Ld. Counsel for OP as none has appeared on behalf of complainant to argue.  However, we have perused the material placed on record by both the parties.  The only ground which has been taken on behalf of National Insurance Company (OP) has been that the complainant was having pre existing disease which he did not disclose at the time of taking the policy.  It is well settled that non disclosure of pre existing disease is a fatal to the claim which leads to rejection thereof. 

          In the present case, if the discharge summary of Sir Ganga Ram Hospital is perused, it is noticed that it has been stated in the Clinical History that Mr. Anthony, complainant, was a patient follow up operated case of Right Frontal Meningioma operated in 2005 present with history of swelling in forehead region since 2-3 weeks.

          Under the column Clinical Summary, it has been stated that patient was admitted with above mentioned complaints as a case of Recurrent Right Frontal Meningioma, underwent Bifrontal Craniotomy and total tumor excision under G.A. on 25.04.2013.  The fact that the complainant was having Right Frontal Meningioma operated in 2005 and for the same disease, he took the treatment from Sir Ganga Ram Hospital, which he did not disclose at the time of taking the policy, non disclosure amounts to breach of condition for the policy.  Therefore, when the complainant have breached one of the condition of the policy, he cannot claim that his claim was wrongly rejected.  Therefore, no ground is made out for survival of this complaint which stands dismissed.  There is no order as to cost.    

          Copy of the order be supplied to the parties as per rules.

          File be consigned to Record Room.

 

 

 

(DR. P.N. TIWARI)                                              (HARPREET KAUR CHARYA)

       Member                                                                             Member    

 

 

            (SUKHDEV SINGH)

                   President            

 

 

It was stated that as per discharge summary, the diagnosis was Recurrent Right Frontal Parasagital meningioma, with clinical history as under:

“A 50 year old male patient follow up operated case of Right Frontal Meningioma operated in 2005 present with history of swelling in forehead region since 2-3 weeks.  he also complains of intermittent headache since then alongwith memory disturbances.  History of increased frequency of Micturation present alongwith constipation”.