BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No. 609 of 2014

Date of Institution: 19-11-2014

Date of Decision: 02-09-2015  

Shri Ranjit Singh aged 31-32 years, son of S.Sawinder Singh, resident of H.No. 477/24, Amrit Dhaba, Guru Nanak Wara, Near Khalsa College, Amritsar.

Complainant

Versus

1. National Insurance Company Limited, having its Corporate Office at 702, Vikrant Tower, Rajindera Plaace, New Delhi through its Corporate Officer. 
2. National Insurance Company Limited, having its office at 93, District Shopping Complex, First Floor, Near Passport Office, Ranjit Avenue, Amritsar through its Branch Manager.
3. Park Mediclaim functioning at Deep Complex, Court Road, Amritsar through its Branch Manager.
4. Fortis Escort Hospital functioning at Majitha-Verka Bye Pass Road, Amritsar through its Director/Unit Head.    

Opposite Parties

Complaint under section 11 and 12 of the Consumer Protection Act, 1986 as amended upto date.

Present: For the Complainant: Sh.A.K.Vermani, Advocate

              For the Opposite Parties No.1 to 3: Sh.S.K.Devassar, Advocate

             For Opposite Party No.4: Sh.Sanjeet Singh, Advocate

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Mr.Anoop Sharma, Member  

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by Sh.Ranjit Singh under the provisions of the Consumer Protection Act alleging therein that he obtained mediclaim insurance policy bearing No.401200/48/08/ 8500001488 from Opposite Parties No.1 to 3 valid for the period from 4.2.2009 to 3.2.2010 which was cashless policy upto the extent of Rs.2 lac. The complainant thereafter, had kept on renewing the aforesaid policy on different intervals and he was issued a new insurance policy bearing No. 401200/48/10/85/00000095 valid for the period from 19.4.2010 to 18.4.2011 and thereafter, the policy was renewed for the period w.e.f. 19.4.2011 to 18.4.2012 and new policy No. was 401200/48/11/85/00000096 was issued  and thereafter identical policy was issued for the year w.e.f. 2012-13 and finally insurance policy No.401200/48/13/85/00000074 was issued for the period w.e.f. 19.4.2013 to 18.4.2014. On 12.11.2013, the complainant had fallen uncomfortable and he had gone to Fortis Escorts Hospital i.e. Opposite Party No.4 for his check up and the doctor there had advised to the complainant to undergo test of ECO Cardiography and the treating doctor  told to the complainant that he is having blockage in the heart valves and he was advised to get himself admitted in the hospital for operation. The complainant thereafter, had told the doctor that he is having a medical insurance for Rs.3.50 lacs which was enhanced from different intervals i.e. initially such policy was for an amount of Rs.2 lacs, but subsequently, at the time of taking last policy, it was  enhanced to Rs.3.50 lacs. The complainant had told  this fact to the doctor attending, upon the complainant that he is a poor person. Although he is having a medical insurance policy, but he can get his treatment done only if the Opposite Party No.4 hospital shall honour the aforesaid insurance policy. The complainant had submitted his card and policy to them and the Opposite Party No.4 thereafter had a  talk with the officials of Opposite Parties No.1 to 3 and ultimately it told to the complainant that they have received approval/ sanction of Rs.2 lacs vide letter No.NICCHI/17816/G-207616 of dated 20.11.2013. Opposite Party No.4 had also clarified to the complainant that a sum of Rs.2 lacs shall be paid by Opposite Parties No.1 to 3 against his insurance policy. The complainant by believing the aforesaid facts got himself admitted in the hospital and was operated upon. On the day of discharge of the complainant on 29.11.2013 the complainant was told that the Opposite Parties  No.1 & 2 have refused to honour the claim and they have rejected the claim vide letter dated 29.11.2013 and had further told to the complainant to deposit cash amount of Rs.3,41,743/-. However, on the request of the complainant, Opposite Party No.4 allowed the complainant to deposit the same in installments. Thereafter, the complainant had been pursuing with the matter but the Opposite Parties No.1 to 3 did not pay the insurance amount, rather  vide letter dated 5.2.2014, the Opposite Parties  No.1 & 2 refused to pay the aforesaid claim by giving the frivolous and false reason and they had submitted that the Opposite Parties  No.1 & 2 have received an intimation that the complainant had taken treatment from Nayyar Hospital. The reasons being so assigned by Opposite Parties  No.1 & 2 in their letter dated 5.2.2014 were totally uncalled for.                         Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite parties No. 1 to 3 to settle the entire claim of the complainant and to pay a sum of Rs.2,66,744/- either to Opposite Party No.4  or to the complainant so that the complainant can settle the entire accounts of the Opposite Party No.4; Opposite Parties No.1 to 3 may be directed  to pay an amount of Rs.75,000/- to the complainant which has been paid by him to Opposite Party No.4 which amount is fully ensured alongwith interest @ 18% per annum. Compensation and litigation expenses were also demanded.
2. On notice, Opposite Parties No. 1 to 3 appeared and filed written version in which it was submitted that the complainant was hospitalized at Escorts Health and Super Specialty Institute Limited from 22.11.2013 to 29.11.2013 with diagnosis Rheumatic Heart Disease, Severe Mitral Stenosis, Moderate Aortic Stenosis with Atrial Fibrillation for which he underwent Double Valve Replacement on 23.11.2013. Further, information is available that the patient had history of admission with same presentation at Nayyar Hospital on 19.9.2009. The complainant is covered under Individual Mediclaim Policy since 19.4.2010 only since the policy in 2010 was renewed after a period of break in insurance of ore than two months. Individual Mediclaim policy does not cover the expenses incurred on treatment of all diseases which are pre-existing  when the cover incepts for the first time (19.4.2010 in this case) vide exclusion clause 4.1. So, the claim is not admissible and in respect thereof the letter dated 3.1.2014 which was duly written by Park Mediclaim TPA Private Limited to the Opposite Parties No.1 to 3, is self explanatory and even the complainant was duly apprised regarding repudiation of impugned claim vide repudiation letter dated 13.2.2014, but all these material facts have been  suppressed by the complainant and as such, the present complaint merits dismissal on this simple score only.           While denying and controverting other allegations, dismissal of complaint was prayed.
3. Opposite Party No.4  appeared and filed written version in the shape of affidavit of Dr.Pinak Moudgil in which it was submitted that the present complaint is filed by the complainant only to delay the pending outstanding due for the satisfactory treatment the complainant had undertaken. There is no element of any negligence in the services rendered by Opposite Party No.4 to the complainant and nor  the same has been alleged in the complaint. During the course of medical treatment of the complainant in Opposite Party No.4, the total costs of treatment amounted to Rs.3,41,744/- and out of which, the complainant had paid Rs.75,000/- and the balance amount  of Rs.2,66,744/- is outstanding  still today. The present complaint is a gross abuse of the process of laws, totally uncalled for and not maintainable. While denying and controverting other allegations, dismissal of complaint was prayed.
4. Complainant tendered into evidence his affidavit Ex.CW1/A alongwith documents Ex.C1 to Ex.C17 and closed the evidence on behalf of the complainant.
5. Opposite Parties No.1 to 3  tendered into evidence affidavit of Sh.H.S.Chawla, SDM Ex.OP3 alongwith documents Ex.OP4 to Ex.OP12. OP1 is discharge summary and  OP2 is summoned complete treatment file of Ranjit Singh Ex.OP2 (containing 26 pages) and closed the evidence on behalf of the Opposite Parties No. 1 to 3.
6. Opposite Party No.4 tendered into evidence the affidavit of Dr.Pinak Moudgil Ex.OP4/1 alongwith documents Ex.OP4/2 to Ex.OP4/9 and closed the evidence on behalf of Opposite Party No.4. 
7. 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 both the parties.
8. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that the complainant got mediclaim insurance policy bearing No.401200/48/08/ 8500001488 from Opposite Parties No.1 to 3 valid for the period from 4.2.2009 to 3.2.2010 (Ex.C11) with sum assured of Rs.2 lacs  which was cashless policy. The complainant got new insurance policy for the period from 19.4.2010 to 18.4.2011 Ex.C13/1 and thereafter, renewed the same policy for the period from 19.4.2011 to 18.4.2012 Ex.C13 and finally insurance policy No.401200/48/13/85/00000074 was issued for the period w.e.f. 19.4.2013 to 18.4.2014 Ex.C13 with enhanced sum insured of Rs.3.5 lacs. On 12.11.2013, the complainant fell ill and consulted Opposite Party No.4- Fortis Escort Hospital, Majitha-Verka Bye Pass Road, Amritsar who conducted the test of  ECO Cardiography of the complainant. The complainant was admitted in Fortis Escort Hospital, Majitha-Verka Bye Pass Road, Amritsar on 22.11.2013 and was discharged on 5.12.2013 as per discharge summary Ex.OP1. complainant told Opposite Party No.4 that he has cashless insurance policy with Opposite Parties  No.1 & 2 and he told Opposite Party No.4 that he can  get his treatment done only if the Opposite Party No.4 hospital shall honour the aforesaid insurance policy. The complainant also consulted the officials of Opposite Parties  No.1 & 2 in this regard and ultimately, it was told to the complainant/ patient that they have received approval/ sanction of Rs.2 lacs from  Opposite Party No.3-TPA vide letter dated 20.11.2013 Ex.C9. Opposite Party No.4 had also clarified to the complainant that a sum of Rs.2 lacs shall be paid by Opposite Parties  No.1 & 2 against the insurance policy. However, lateron Opposite Parties  No.1 & 2 vide letter dated 29.11.2013 Ex.C6/A withdrawn the aforesaid cashless facility of Rs.2 lacs and the complainant had to pay the amount of treatment to Opposite Party No.4 and Opposite Party No.4 allowed the complainant to pay the balance amount in installments. Complainant paid Rs.75,000/- to Opposite Party No.4 and balance of Rs.2,66,740/- is yet to be paid by the complainant to Opposite Party No.4. Opposite Parties  No.1 & 2 repudiated the claim of the complainant vide letter dated 5.2.2014 Ex.C1 on the ground of pre-existing  disease which is not covered  as the policy covers expenses of treatment taken for pre existing disease after 4 years of incepts as per clause 4.1 of the policy. Ld.counsel for the  submitted that the complainant was not suffering from any such disease prior to the inception of the policy. Further the complainant got the treatment from Opposite Party No.4 on the assurance of Opposite Party No.3-TPA who granted/ allowed the cashless facility of Rs.2 lacs vide letter Ex.C9 and the Opposite Party No.4 assured that Rs.2 lacs will be paid by Opposite Parties  No.1 & 2, but lateron Opposite Parties  No.1 & 2  had withdrawn this cashless facility vide letter Ex.C6/1. Not only this, they have repudiated the entire claim of the complainant on the ground of pre-existing disease. Ld.counsel for the   complainant  submitted that all this amounts to deficiency of service on the part of the opposite parties.
9. Whereas the case of the Opposite Parties No. 1 to 3 is that the complainant was hospitalized at Fortis Escort Hospital, Majitha-Verka Bye Pass Road, Amritsar from 22.11.2013 and was discharged on 5.12.2013 as per discharge summary Ex.OP1 with diagnosis Rheumatic Heart Disease, Severe Mitral Stenosis, Moderate Aortic Stenosis with Atrial fibrillation for which he underwent Double Valve Replacement on 23.11.2013. The complainant has been covered under Individual Mediclaim Policy since 19.4.2010 which was  renewed after a period of break in of more than  two months of earlier policy. Individual Mediclaim policy does not cover the expenses incurred on treatment of all diseases which are pre-existing  when the cover incepts for the first time on19.4.2010 vide exclusion clause 4.1 of the policy. As such, the  claim is not admissible and in this regard,  letter dated 3.1.2014 Ex.OP7  was duly written by Opposite Party No.3-TPA the Opposite Parties No.1 & 2 and the complainant was duly informed by Opposite Parties  No.1 & 2 vide letter dated  13.2.2014 Ex.OP6. However, the complainant has concealed the material facts while taking the policy. Earlier, the complainant was admitted in Nayyar Hospital, Amritsar on 14.4.2009 and was  discharged on 16.4.2009 as per patient record of Nayyar Hospital, Amritsar Ex.OP2 running into 26 pages which has duly been proved by Sh.Bikramjit Singh,  Co-ordinator of Nayyar Heart Institute  and Super Specialty  Hospital, Amritsar. As per this record at page 18, the complainant had undergone BMV (Bellary of Mitral Valve) treatment, but the complainant has concealed this fact while taking the policy Ex.C13/1 for the period from 19.4.2010 to 18.4.2011. So, the complainant has obtained the policy Ex.C13/1 by concealment of facts i.e. by concealing the pre-existing heart disease for which the complainant had already undergone medical treatment at Nayyar Hospital, Amritsar for the period from 14.4.2009 to 16.4.2009. Ld.counsel for Opposite Parties  No.1 to 3 submitted that the Opposite Parties  No.1 to 3 were justified in withdrawing the cashless facility already granted vide letter Ex.C9 and also repudiated the claim of the complainant vide letter dated 13.2.2014 Ex.OP6. As such, there is no deficiency of service on the part of Opposite Parties No.1 to 3 qua the complainant.
10. Whereas the case of Opposite Party No.4 is that the complainant was admitted in Opposite Party No.4 Hospital and the patient/ complainant showed  his card of Park Medi-claim-Opposite Party No.3 and informed the hospital that under the said card his expenses to the extent of Rs.2 lacs are covered by the Opposite Parties  No.1 & 2 under the aforesaid policy and the excess expenses shall be paid by him. The hospital staff assisted in forwarding his treatment record to Opposite Party No.3-TPA and Opposite Party No.3-TPA issued  letter dated 20.11.2013 Ex.C9 authorizing the cashless treatment upto Rs.2 lacs. Patient/ complainant was informed accordingly and the patient was admitted in Opposite Party No.4 hospital on 22.11.2013 and he signed the undertaking dated 22.11.2013 that he shall pay the entire amount of treatment before leaving hospital. Even at the time of discharge from the hospital, relative of the complainant gave undertaking Ex.OP12 dated 5.12.2013 that he would deposit the entire amount to the hospital after getting reimbursement from Opposite Party No.3-TPA. So, the complainant was bound to pay the entire treatment amount to Opposite Party No.4. Complainant could not point out any negligence or deficiency of service on the part of the Opposite Party No.4 qua the complainant. Ld.counsel for the Opposite Party No.4 submitted that there is no deficiency of service on the part  of Opposite Party No.4 qua the complainant.       
11.  From the entire above discussion, we have come to the conclusion that the complainant obtained first policy from Opposite Parties  No.1 & 2 for the period from 4.2.2009 to 3.2.2010 Ex.C11. Thereafter, the complainant did not get renewed the said policy and he got a new insurance policy from Opposite Parties  No.1 & 2 for the period from 19.4.2010 to 18.4.2011 Ex.C13/1 with gap of about 2 ½ months from the first policy which expired on 3.2.2010. Thereafter, the complainant got this policy renewed for the period from 19.4.2011 to 18.4.2012 Ex.C13 and then the complainant further got renewed the said policy for the period from 19.4.2013 to 18.4.2014 Ex.C12 with enhanced sum assured of Rs.3.5 lacs. The complainant became ill on 12.11.2013 and he got himself checked from Opposite Party No.4- Fortis Escort Hospital, Majitha-Verka Bye Pass Road, Amritsar and he was admitted in Opposite Party No.4-Hospital on 22.11.2013 and was discharged on 5.12.2013 as per discharge summary Ex.OP1. The complainant was diagnosed Rheumatic Heart Disease, Severe Mitral Stenosis, Moderate Aortic Stenosis with Atrial fibrillation for which he underwent Double Valve Replacement on 23.11.2013. The complainant has  history of admission with same disease as per treatment at Nayyar Hospital, Amritsar on 14.4.2009. complainant  has been covered continuously under Individual Mediclaim Policy since 19.4.2010. The complainant has got this policy for the period from 19.4.2010 to 18.4.2011 Ex.C13/1 after a gap of period of more than 2 months as his earlier policy has expired on 3.2.2010 i.e. policy Ex.C11. As per record of Nayyar Hospital, Amritsar Ex.OP2 which has been duly proved by Sh.Bikramjit Singh,  Co-ordinator of Nayyar Heart Institute  and Super Specialty  Hospital, Amritsar, the complainant was admitted in Nayyar Hospital, Amritsar on 14.4.2009 and was discharged on 16.4.2009 and during this period he had undergone treatment of BMV (Bellary of Mitral Valve) treatment i.e. heart disease, but while taking this policy for the period from 19.4.2010 to 18.4.2011 Ex.C13/1, the complainant has concealed this material fact from Opposite Parties  No.1 & 2. The complainant has not rebutted this documentary evidence produced on record by Opposite Parties  No.1 & 2 which fully proves that the complainant remained admitted  and had undergone treatment of heart disease at Nayyar Hospital, Amritsar for the period from 14.4.2009 to 16.4.2009. Therefore, it stands fully proves on record that the complainant has obtained this policy Ex.C13/1 for the period from 19.4.2010 to 18.4.2011 by concealment of fact.   It has been held by Hon'ble National Commission in case Life Insurance Corporation of India Vs. Mansa Devi 2003(1) Judicial Reports Consumer 501 that where the insured has suppressed the material facts of existence of any pre-existing disease and had undergone treatment for that, the suppression of such a material fact renders the contract of insurance illegal, invalid, void abinitio and unenforceable. Hon'ble National Commission further held that the contract of insurance is of utmost good faith i.e. Ubremma Fidei and the life assured is bound to disclose honestly, truthfully and correctly all the answers in the proposal form concerning the state of his health. The same view has been taken by the Hon'ble National Commission in case Sr. Divisional Manger, LIC of India Vs. Smt. Satwant Kaur Sandhu Legal Digest April 2011 page 85 as well as in case Panchal Ramabhai Motibhai Vs. LIC of India Legal Digest April 2011 page 83. So the concealment of this material fact by the complainant while obtaining the present policy from the opposite party renders this contract of insurance illegal and void. Hon'ble Supreme Court of India in case Satwant Kaur Sandhu Vs. New India Assurance Company Ltd IV (2009) CPJ 8 (SC) has held that in case of mediclaim policy where the policy holder suffering from chronic diabetes and renal failure, not disclosed while obtaining the medi claim insurance policy, this suppression of material fact has been fully proved by the opposite party. Apart from this Hon'ble Supreme Court of India observed in case Satwant Kaur Sandhu Vs. New India Assurance Company Limited (supra) that:-

“A medi claim policy is a non-life insurance policy meant to assure the policy-holder in respect of certain expenses pertaining to injury, accidents or hospitalizations. Nonetheless, it is a contract of insurance falling in the category of contract ubremma fidei, meaning a contract of utmost good faith on the part of the assured. Thus, it needs little emphasis that when an information on a specific aspect is asked for in the proposal form, an assured is under a solemn obligation to make a true and full disclosure of the information on the subject which is within his knowledge. It is not for the proposer to determine whether the information sought for is material for the purpose of the policy or not. Of course, the obligation to disclose extends only to facts which are known to the applicant and not to what he ought to have known. The obligation to disclose necessarily depends upon the knowledge one possesses. His opinion of the materiality of that knowledge is of no moment.”

12. As the complainant has concealed the material facts while obtaining the policy Ex.C13/1 for the period from 19.4.2010 to 18.4.2011, Opposite Party No.3-TPA was not aware about this fact, as such, they allowed the cashless facility of Rs.2 lacs to Fortis Escort Hospital, Majitha-Verka Bye Pass Road, Amritsar vide letter dated 20.11.2013 Ex.C9, but when the Opposite Party No.3-TPA came to know about the concealment  of these facts by complainant while obtaining the policy Ex.C13/1 for the period from 19.4.2010 to 18.4.2011, Opposite Party No.3 -TPA withdrew this cashless facility of Rs.2 lacs vide letter dated 29.11.2013 Ex.C6/1 by telling Opposite Party No.4-Hospital that as the policy covers expenses treatment taken for pre-existing disease after 4 years of inception, therefore, earlier grant of Rs.2 lacs stands withdrawn. Not only this, the complainant was also informed by Opposite Parties vide letter dated 13.2.2014 Ex.OP6 that the disease was pre existing disease and the new medical policy  does not cover claim  for pre existing disease in light of the above referred facts conveyed vide their letter dated 5.2.2014, the claim of the complainant has been repudiated as per exclusion clause 4.1 of the policy in question. The complainant was admitted in Fortis Escort Hospital, Majitha-Verka Bye Pass Road, Amritsar for the period from 22.11.2013 to 5.2.2014 as per discharge summary Ex.OP1 and he was diagnosed for the heart disease for which the complainant had already undergone  treatment by remaining admitted in Nayyar Hospital, Amritsar for the period from 14.4.2009 to 16.4.2009 as per record of Nayyar Hospital, Amritsar Ex.OP2, so the complainant had pre-existing disease i.e. heart disease. He has concealed this fact from Opposite Parties  No.1 & 2 while obtaining the policy Ex.C13/1 for the period from 19.4.2010 to 18.4.2011. So, all this shows that the conduct of the complainant was not  fair. He has obtained this policy Ex.C13/1 by concealment of facts. Further as per this policy, it covers expenses of treatment taken for pre-existing disease after 4 years of inception whereas the complainant has obtained the policy w.e.f. 19.4.2010 and he was admitted in Fortis Escort Hospital, Majitha-Verka Bye Pass Road, Amritsar and undergone treatment for the pre-existing disease i.e. heart disease for the period from 22.11.2013 to 5.2.2014 as per discharge summary Ex.OP1 which was within the period of 4 years of inception of the policy. Opposite Parties No.1 to 3 are, therefore, justified in repudiating the claim of the complainant vide letter dated 5.2.2014 Ex.C1 and latter dated 13.2.2014 Ex.OP5 as per terms and conditions of the policy.
13. Resultantly, we hold that the complaint is without merit and the same is hereby dismissed with no order as to cost. Copies of the order be furnished to the parties free of cost. 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.

Dated: 02-09-2015.                                                   (Bhupinder Singh)                                                                                               President

hrg                                                (Anoop Sharma)     (Kulwant Kaur Bajwa)   

              Member                         Member