ORDER

Complaint under  Sec.12 of the CPA 1986 as amended upto date

Ms. Nipur Chandna, Member

          Complainant had a mediclaim policy no. 354500/46/09/8500000247 with OP no. 1 for a period w.e.f. 9.11.2009 to 9.11.2010.

     It is alleged by the complainant that the aforesaid mediclaim policy cover the illness of the complainant as well his family members.

      It is alleged by the complainant that on 18.3.2010 his wife was admitte4d in Ram Chand Memorial Nursing Home and was discharged on 31.3.2010, and for this period hospital raised a bill amounting to Rs.71,496/-.

     It is further alleged by the complainant that his wife was again admitted in the aforesaid hospital  on 12.5.2010 to 19.5.2010 and for this hospital has raised the bill of Rs.73,338/-.

It is alleged by the complainant that OP no. 1 not only refused the cashless facility but also repudiated his aforesaid claims on the following grounds.

10. That without any rhyme and reason, the opposite party no. 2 has for and on behalf of the opposite party no. 1, rejected the claim of complainant on the following two scores:-

1) THAT THE RAM CHAND MEMORIAL HOSPITAL WAS REGISTERED WITH OPPOSITE PARTY NO. 1 UPTO 31.03.2010 ONLY; AND

II) THAT CERTAIN DISCREPANCIES ALONG WITH INFLATION OF BILLS WERE OBSERVED DURING INVESTIGATION OF THE CASE.

     It is alleged by the complainant that despite his several requests and visits to the office of OP no. 1 no heed was paid to his plight; The complainant therefore approached this Forum for the redressal of his grievance.

     OP s have contested the complaint.  A written statement has been filed by the OPs.  Para No. 7 of preliminary objection of the W.S. filed by the OP is relevant for deciding the present complainant and is reproduced as under:-

7.That the complainant has concealed the material facts from this Hon'ble Court, therefore, the complaint is liable to be dismissed.

true facts of the case are that a Group Personal Accident Insurance was issued for the employees of Ericsson India Pvt. Ltd. and complainant being the employee of the said company along with his family were insured under the said policy and the liability of the company was subject to terms and conditions of the said policy i.e. bearing No. 354500/46/09/850000247 from 09.11.2009 to 08.11.2010 for a sum of Rs. 1,50,000/- to each member of family of the employee. However, out of the claim amount 10% of the said claim amount is to be paid by the employee himself as per Clause 5.2.1. In the present case on receiving the claims of the complainant the company appointed Dr. Vishwas Bardhan to investigate into the matter who after investigation submitted his report dated 24.06.2010 in each case i.e. in both hospitalization from 18.3.2010 to 31.03.2010 & 12.05.2010 to 19.05.Olei and in Lod1 the cases he submitted that the hospital is registered upto 31.03.2010 whereas the renewal of the hospital is not made available. The hospital was registered for 8 inpatient beds only. There are other discrepancies noted in payment receipt, medical bills, ultrasonology charges, laboratory charges and daily cash collection of the hospital, which shows that there is a manipulation of the hospital and inflated bills are prepared illegally and unlawfully. Thus, the claim is not maintainable accordingly, the claim was repudiated vide letter dated 28.06.2010 respectively. Accordingly, the claim is not maintainable and is liable to be dismissed.

Both the parties have filed their evidence by way of affidavit.

We have heard the arguments advanced at bar and have perused the record.

          Counsel for the OP has contended that as per clause no. 5.28 of the insurance policy, the hospital where the treatment is taken should be either a network hospital or in case of non-network hospital it should have at least 20 in patients beds.  It is contended that hospital where patient has taken treatment was registered for 8 beds in hospital and that too upto 31.3.2010 thereafter no record of its further registration was made available, therefore the said hospital was not covered under the definition of the hospital as per the policy.

     It is further contended by the counsel for the OP that some discrepancies were noted in payment receipt, medical bills, laboratory charges etc. which shows that there is a manipulation of the hospital records and inflated bills were prepared illegally and unlawfully. 

          The OP had appointed Dr. Vishwas Bardhman as an Investigator and has placed on record a copy of the investigation report of Dr. Vishwas Bardhman.  Dr. Vishwas Bardhman has also filed his own affidavit in support of his aforesaid report.

          It has been claimed that the aforesaid claim has been rightly repudiated in light of the policy terms and conditions.  It has been prayed that the complaint be dismissed.

          We are in agreement with the contention of the counsel for the OP the bare perusal of the investigation report of the Dr. Vishwas Bardhman reveals the truth of the contention submitted by the counsel for the OP .  The Hospital where the patient has taken treatment does not fall under the definition of the hospital as per the policy terms and conditions.

The foundation of an insurance contract is uberrima fide.  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.”

In view of the above judgment, report of the Investigator, we are of the considered opinion that the OP has justified repudiating the claim lodged by the complainant.  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.....................