DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
UDYOG SADAN, C-22 & 23, QUTUB INSTITUTIONAL AREA
(BEHIND QUTUB HOTEL) : NEW DELHI – 110016.
Case No. 299/08
Tejinder Singh Oberio
S/o Sh. Raj Singh Oberio
R/o A-466, Double Storey, Kalkaji,
New Delhi. - Complainant
Vs
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12, Community Centre
-
New Delhi – 110065.
Through its Branch Manager
-
Plot No.-8, 3rd Floor Business Retail Centre
Nangal Raya, Opp. Janakpuri, Block-B,
New Delhi - Opposite Parties
Date of Institution: 12.05.2008 Date of decision: 11.05.2016
Coram:
N.K. Goel, President
Naina Bakshi, Member
S.S. Fonia, Member
O R D E R
S.S. Fonia, Member
Briefly stated, the complainant along with his wife insured with OP-1 vide Mediclaim Policy bearing No. 351701/48/05/8500001943 for the period w.e.f. 21.2.06 to 20.2.07 (Annex. C-I). The complainant and his wife are said to have been physically checked up by the OPs before accepting the proposal form. The policy was issued under Family Health Plan with endorsement that, “this insurance is subject to Hospitalization and Domiciliary Hospitalization”. OPs accepted Rs. 6921/- from the complainant towards premium. The complainant got treatment from Patel Poly Clinic during 2.11.06 to 6.11.06 with ailment diagnosed as diabetes. After two months, the complainant was admitted in Holy Family Hospital, New Delhi on 2.1.2007 and discharged on 4.1.07. The case summary of the Holy Family Hospital is annexed as Annex. C-2. Thereafter, the complainant was admitted to Escorts Heart Institute & Research Centre, Okhla, New Delhi for further treatment on 5.1.07 and was discharged on 22.1.07. Discharge Summary is annexed as Annex. C-3. The complainant states that in the history and follow up it has been clearly stated that “No Past History of Hypertension but Past History of diabetes of two months”. The complainant after being admitted in Escorts Heart Institute submitted the Insurance document for “Cashless Service” but the same was denied on 8.1.2007 under the note of OPs as mentioned in Anex. C-4 which inter-alia indicates that, “Please note that the denial of authorization for cashless access does not imply the denial of treatment and does not in any way prevent you from seeking necessary medical attention or hospitalization and lodging your claim for reimbursement which will be processed on merit”. The complainant further states that as per the case summary of Holy Family Hospital i.e. Annex. C-2, he was recently detected diabetes type 2 (2 months back). The complainant further states that on 20.9.07, the OPs opined that the claim does not fall under the preview of the Policy for the following reasons: “The present hospitalization is for the management of an ailment which is related to a Pre-existing condition”. The complainant further states that the OPs had further insured the complainant and his wife for the year 2007-08 under the same Mediclaim Policy. The complainant is said to have submitted bills totalling to Rs.305769/- as per the document marked as Annex. ‘A’ for identification but he was entitled to Rs. 3,00,000/- as per the mediclaim policy. The OPs having declined the claim for want of supplying any document as a proof of past ailment triggered him to lodge this complaint before this Forum on account of deficiency in service by the OPs. The complainant is said to have served legal notice to the OPs wherein the OPs have repeated the same allegations with false presumptions and assumptions. The complainant has prayed this Forum to clear the mediclaim bills of the complainant and award Rs. 50,000/- for causing harassment and mental torture and Rs. 11,000/- towards legal expenses.
OPs have denied the allegations in their reply by contending inter-alia that “the patient is suffering from Diabetes since last 3 years on Tablet Doanil”. They have further replied that “since the policy is from 21.2.06 so this disease is pre-existing. Hence, the claim was found not payable as per condition no. 4.1 of the policy and was rightly repudiated vide letter dated 20.9.2007 in respect of claim Id. Del 81877”. With regard to another claim of the complainant vide Id. Del 81878, the OPs have stated that the authorized claim settler of the OPs had time and again requested the claimant to provide treatment record with respect to past treatment record with treating doctor certificate regarding 1st Diagnosed IHD/DM2, Original Echo Report with Trop T strip with Lipid Profile reports and finally when no documents were provided to the claim settler of the OPs even after repeatedly asking for it, they were forced to repudiate the same for the reason given in their rejection letter dated 20.9.2007. It is prayed that the complaint be dismissed.
Complainant has filed replication ascertaining the averments made by him in the complaint and denying the allegations made by the OPs.
Complainant has filed his own affidavit in evidence. On the other hand, affidavit of Sh. K.P. Singh, Senior Divisional Manager has been filed on behalf of OPs.
Written arguments have been filed on behalf of both the parties.
We have heard the arguments on behalf of the OPs and carefully examined the material placed before us dispassionately.
Now, we straightway come to address the question, whether the relief prayed for is admissible to the complainant?
Admittedly, the complainant and his wife were insured with OP-1 for Hospitalization and Domiciliary Hospitalization benefits for the period w.e.f. 21.2.06 to 20.2.07. The complainant was treated in Patel Poly Clinic with prescription of Tablet Doanil x ½ OD on 6.11.06 [Annex. C-1, page 2 (marked by us)]. He was further admitted in Holy Family Hospital on 2.1.07 with diabetic type 2 (2 months back) and discharged on 4.1.07 (Annex. C-2). C-2 inter-alia describes “At present he is being managed conservatively as a case of severe AS, DM Type II with retinopathy, IHD, Dyslipidemia, and is hemodynamically stable”. There is no mention of past history of diabetes in the “case summary” of Holy Family Hospital vide Annex. C-2. He was further admitted in Escorts Heart Institute & Research Center on 5.1.07 and discharged on 22.1.07 vide discharge summary (Annex. C-3). In diagnosis column the complainant was inter-alia found to be suffering from “TYPE 2 DIABETES MELLITUS”. Very interestingly the full copies of discharge summary of Escorts Heart Institute and Research Centre have not been filed by the complainant. Had they been filed on the record, this forum would have the option to go through the history of diseases which must have been certainly mentioned in the “HISTORY” Column of the discharge summary. Thus, the complainant has intentionally suppressed a very very material document from the forum which is sufficient to raise an adverse presumption against him. The OPs vide their letter dated 8.1.07 had refused to issue authorization/credit letter to the Escorts Heart Institute with the following reasons:
“Doctors Note: As PED cannot be definitively ruled out. It is a fresh policy as per our records. However member can go for reimbursement with all previous insurance and medical records. It can be settled as per merits of the case.”
The lapse, if any, on suppression of material facts on behalf of the complainant does not absolve the OPs to prove the facts the onus of which is on them. From the medical records produced on behalf of the complainant it stands proved that at the time of getting the medical treatment from the above hospitals, the complainant was suffering from diabetes Type-2 for the last 2 months. However, from this fact it cannot be concluded that the complainant was in fact suffering from diabetes for the last 3 years. Therefore, in our considered opinion, OPs have failed to prove that the complainant was suffering from any pre-existing disease at the time of taking the policy in question from the OPs.
In the light of above documents at C-2 and C-3, no past history of diabetes as stated by the OPs is revealed. Therefore, the contention of OPs that the complainant was suffering from diabetes since last 3 years in their written statement is false. As regards contention of OPs to admit the case of the complainant by submitting the documents to prove the past history, we are of the view that once contract is entered for insurance, OPs cannot insist upon the insured for giving documents to prove the past history of the ailments. This requirement, if though essential, has to be met before accepting the proposal from the insured i.e. the complainant. It is pertinent to cite extract of the following Judgment of the National Commission in Praveen Damani Vs. Oriental Insurance Co. Ltd., IV (2006) CPJ 189 (NC). The National Commission paid special attention to the exclusion Clause 4.1 of the Medical Clause Policy as under:
“It is not relevant whether the insured person had knowledge of the existence of a disease or not. If symptoms of the disease existed before the effective date of insurance and even if the insured person was not aware of these symptoms, the insurance company was not liable to pay any claims arising out of the condition. If this interpretation of the Exclusion Clause was to be accepted , then, the insurance company would not be liable to pay any claims whatsoever, because most people suffer from symptoms of diseases without the knowledge of the same.”
The National Commission noted that:
“The policy is not a policy at all as it is just a contract entered only for the purpose of accepting the premium without the bone fide intention of giving any benefit to the insured under the garb of pre-existing disease. Most of the people are totally unaware of the symptoms of the disease that they suffer and hence, they cannot be made liable to suffer because the insurance company relies on their Exclusion Clause 4.1 of the policy in a mala fide manner to repudiate all the claims. No claim is payable under the mediclaim policy as every human being is born to die and diseases are perhaps pre-existing in the system totally unknown to him which he is not aware of.”
It is further held:
“In hindsight, everyone realizes much later that the symptoms were indicative of a disease. But common people are not at all familiar with the medical knowledge and so they cannot diagnose their own diseases. If they were expected to be so aware of their medical condition at all times, there would be no use of insurance policies.”
In view of the foregoing discussions, we allow the complaint and direct the OP-1 to pay Rs. 2,55,500/- (medical expenses incurred at Escorts Heart Institute. Copy Annex. X for identification) and Rs. 50,000/- towards compensation of harassment and mental agony to the complainant within 30 days from the date of filing of the complaint till realization failing which OP-1 shall become liable to pay Rs. 2,55,500/- along with interest @ 6% p.a. from the date of filing of the complaint till the actual payment.
Copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
Announced on 11.05.2016.
(S.S. FONIA) (NAINA BAKSHI) (N.K. GOEL) MEMBER MEMBER PRESIDENT
Case No. 299/08
11.5.2016
Present – None
Vide our separate order of even date pronounced, the complaint is allowed. OP-1 is directed to pay Rs. 2,55,500/- (medical expenses incurred at Escorts Heart Institute. Copy Annex. X for identification) and Rs. 50,000/- towards compensation of harassment and mental agony to the complainant within 30 days from the date of filing of the complaint till realization failing which OP-1 shall become liable to pay Rs. 2,55,500/- along with interest @ 6% p.a. from the date of filing of the complaint till the actual payment. Let the file be consigned to record room.
(S.S. FONIA) (NAINA BAKSHI) (N.K. GOEL) MEMBER MEMBER PRESIDENT
