ORDER
NIPUR CHANDNA, MEMBER
In United India Insurance Co. Ltd. Vs. M.K. Corporation,III(1996)CP 8(SC), the Hon’ble Supreme Court held as under :-
“It is a fundamental principle of Insurance Law that utmost good faith must be observed by the contracting parties. Good faith forbids either party from concealing (non disclosure) what he privately knows, to draw the other into a bargain, from his ignorance of that fact and his believing the contrary. Just as the insured has a duty to disclose, ”Similarly, it is the duty of the insurers and their agents to disclose all material facts within their knowledge since obligation of good faith applies to them equally with the assured.
The duty of good faith is a continuing nature. After the completion of the contract, no material alteration can be made in its terms except by mutual consent.
Coming to the facts of this case, it may be stated that the complainant had taken a mediclaim policy from the OP which was valid from 23.10.2010 to 22.10.2011. It was renewed for a period of another year w.e.f. 27.10.2011 to 26.10.2012. it is alleged by the complainant that on 24.8.2011 he was admitted in Care Asia hospital , Rewari and was discharged after a period of four days . He had incurred a sum of Rs. 41,103 on his treatment. He had lodged a claim with the Ops which was repudiated. The complainant has alleged that the act of repudiation is unwarranted and is an act of deficiency in service on the part of the OPs. Hence, the complaint.
The OP has contested the complaint and has filed a written statement.
It has denied any deficiency of service on its part and has claimed that the complaint is liable to be dismissed. It has claimed that the complainant has not approached the forum with clean hands and has tried to mislead.
The Op has contested the complaint on merits. it has admitted that it had issued a policy of insurance in favor of the complainant during the subsistence of which it had received information about the admission of the complainant in the hospital. It has ,however, claimed that on the , the reinvestigation of the claim it was found to be bogus and manipulated. It had , therefore, repudiated the claim. It has claimed that the complaint has no merits and is liable to be dismissed.
We have heard arguments advanced at the bar and have perused the record.
On behalf of the OP an affidavit has been filed by sh. I.K. Kanwadia, an administrative officer. Paras 2 , 5 , 6 , 7 ,8 and 9 of his affidavit are relevant and are being reproduced as under:
2. I Say that the present claim is manipulated by the Hospital with the consent of the insured as per the investigation report submitted by Raksha TPA Pvt. Ltd. The copy of the report has already been placed on record by the complainant.
5. I say that the complainant was admitted to directly to ICU without any check-up and was also discharged from there and was not even advised to visit the hospital for check-up again. All the record of nursing was maintained by a single person only, and no medicine prescription prescribed by the doctor along with the claim papers was submitted.
6. I say that the complainant never informed to the company about admission to the Hospital for treatment although the insured was having cash less insurance policy as admitted by the complainant. I say that on account of failure of the complainant in informing about admission as required under the policy resulted in non-investigation of his mediclaim.
7. I say that the complainant did not visit the hospital for checkup. I say that the complainant was admitted in the hospital straight way for admission in ICU as already fixed I say that even the duration of admission of 4 days was predetermined. I say that the entire nursing chart was maintained by the single person and the same person has signed the payment received as well as the discharge summery. I say that the investigator after considering all these points concluded that the claim is manipulated with the consent of the insured.
8. I say that the admission treatment record is manipulated as per the opinion of the TPA on the basis of investigation carried out by them.
9. I say that the claim submitted by the insured is manipulated as opined by the TPA investigator and is rightly repudiated.
The OP has also placed on record an affidavit of Sh. S. S. Sajwan, a manager of the Raksha TPa PVT Ltd. who had investigated the claim . Para 4 of the affidavit sworn by Sh. S. S. Sajvwan is reproduced as under;
4. I say that claim in respect of Narender Yadav was investigated by the undersign ed on 24.12.2011 and following facts were observed :
Claim falls under the first year of policy
- Patient got admitted in ICU and was discharged directly from ICU which is unusual (4 day stay).
• Nursing chart was maintained in same handwriting for whole hospitalization period.
• No prescription was enclosed in the claim documents.
• ICU charges i.e Rs. 6000/- per day are on higher side for a city like Rewari.
• Case pertains to fever but no, temperature charting is maintained by hospital
• It was concluded that the claim is manipulated by the hospital with the consent of insured. Further, the claim file along with our detailed investigation report, and recommendations was forwarded to Respondent no.1 i.e Divisional Office of The National Insurance Co. Ltd., on 12-04-2012 for their kind perusal, and further decision on the claim.
In view of the affidavits filed on record on behalf of the OP s , we are unable to hold that there was a deficiency in service on the part of the OP. The OP had got the case investigated and had come to the conclusion that the claim was manipulated. It was, therefore, within its rights to reject the claim. We see no merits in this complaint. the same is hereby dismissed.
Copy of the order be made available to the parties as per rule.
File be consigned to record room.
Announced in open sitting of the Forum on.....................
