ORDER
RAJBIR SINGH DAHIYA, PRESIDENT:
1. Brief facts of the complaint that complainant had taken a Mediclaim Policy from the respondent vide policy no. 272490/48/2016/178.The period of alleged policy w.e.f 30.10.2015 to 29.10.2016 with a sum assure of Rs. 6.00 lac. That on 11.02.2016 the complainant was admitted in Asian Institute of Medical Sciences, Sector-21A, Faridabad, where he remained hospitalized from 11.02.2016 to 13.02.2016 and he was discharged from the said hospital on 13.02.2016. That the complainant had spent Rs. 29030/- on medical treatment as indoor patient and hospitalization and he informed to the respondent company on the very same day but the respondent has refused to encashment the alleged claim to the abovesaid hospital, even having a cashless policy. That even after discharge from the said hospital, as per direction of the respondent, the complainant has sent all the original treatment as well as medical bills alongwith the re-imbursement claim forms to the respondent but the respondent company has not reimbursed the claim of the complainant and denied to reimbursed the claim of the complainant by demanding the baseless documents repeatedly which have already been filed by the applicant to the respondent through the alleged Asian Institute of Medical Science and also furnished by him in the office of the respondent. That the complainant has now any previous decease of any kind and no any treatment was going on prior to this hospitalization and this information has already been furnished alongwith all the relevant demanded documents to the respondents. That as per the terms and conditions of the policy, the case of hospitalization a period of 24 hours should be completed and the applicant had been hospitalized for three days in the alleged hospital, but the respondent has illegally refused to make the payment to the applicant even having a cashless policy. That the complainant is also entitled to get the damages of Rs. 50,000/- due to the harassment sustained by complainant because of their negligence, carelessness committed by the respondent. That earlier an application moved by the complainant before the Permanent Lok Adalat, Nuh on the same cause of action but the same was dismissed as withdrawn on 12.01.2018 with liberty to file the present before any competent forum or court. Hence, this complaint with prayer to direct the respondent to pay amount of hospitalization as indoor patient of Rs. 29030/- alongwith a sum of Rs. 50,000/- on account harassment, mental agony suffered by the complainant due to failure on the part of performance of respondent and also liable to pay Rs. 20,000/- for ligation charges.
2. After registration of complaint, notice was issued to respondent. Respondent in its reply has submitted that as per investigation report, claim form was not found to be genuine and as several discrepancies were found:
1) The name of the patient was added in policy on 30.10.2015 only and no previous policy prior to 30.10.2015 was found. A record of treatment prior to 11.02.2016 was also not found.
2) Coronary Angiography done but no record and bills were found to confirm it.
3) ICU protocol was not maintained.
4) Patient got discharged without advice.
5) Bill book was not shown.
6) Investigation like ECG, ECHO and CAG were done, but no record and bills were found to confirm it.
That compliance of Section 64VB of the policy is yet to be confirmed. That on the basis of evidence and documents collected by the investigating authority, it is concluded that the hospitalization at all is not justified and fraudulent means are adopted and used to make the claim payable and the answering respondent within the ambit of terms and condition of policy has repudiated the claim as per clause-5.8, which is as under:
“Disclosure of information norm the policy shall be void and all premium paid hereon shall be forfeited to the company, in the event of misrepresentation, mis-description or non disclosure of any material facts. As such the claim does not fall within the preview of terms and conditions as such the TPA had repudiated the claim”.
That there is clear and irrefutable evidence of misrepresentation/non disclosure of facts as such the present application is liable to be dismissed. That the insurance is a contract between the insured and insurer and both the parties to the contract are bound by the terms and conditions of the insurance policy. The insurance policy between the insurer and insured represents a contract between the parties, since the insurer undertakes to compensate the loss suffered by the insured on account of risk covered by the insurance policy. The terms of the agreement have to be strictly construed to determine the liability of the insurer. As such, the answering respondent has rightly denied the claim of the applicant.
That there is no deficiency of service as has been laid down by the Hon’ble Supreme Court inc ase titled as Ravneet Singh Bagga Vs. KLM royal Dutch Airlines 2000 1 SCC 66 wherein it has been laid down that the test of deficiency in service lay upon the plaintiff for providing that there was some fault, imperfection, shortcoming or inadequacy in the manner of the insurance company and further such fault etc. must be will full. More importantly the Hon’ble Supreme Court has held that where there is a bonafide dispute between the parties and where service provider has after considering all the material with them and relevant facts has acted in a particular manner, then such acts will not amount to deficiency in service. That the present application is wholly misconceived, groundless and unsustainable in law and same is liable to be dismissed and as such the applicant has not approached this forum with clean hands and suppressed true and material facts pertaining to the present application. That without prejudice to whatsoever has been stated above answering respondent reserve its right to file amended written statement when new and more facts came into the knowledge of the answering respondent.
The respondent company has denied that a sum of Rs. 29030/- has been spent as indoor patient and hospitalization or all the relevant documents have been supplied. It is submitted that the applicant has not supplied the documents required for investigation such as certificate from attending consultant providing
- Cause of Hypoglycemia in this case.
- Any past history of Diabetes, Hypertension, CAD or etch. And all the policy copies confirming covering coverage of the patient under mediclaim policy prior to 30.10.2015, records of treatment taken before hospitalization, signed letter addressed to medical superintendent of the hospital requesting him/her to allow verification inpatient records by TPA, self attested copy of your photo ID proof issues by any Govt. Authority and reason for delay in submission of claim documents after 7 days of discharges from hospital.
It is wrong and denied that the Repudiation was done as per terms and condition of the policy. It is submitted that the applicant has not informed or supplied the relevant documents for the purpose of verification in time and all the relevant documents have been supplied. It is submitted that the applicant has not supplied the documents required for investigation such as certificate from attending consultant providing. It is wrong and denied that applicant had no such medical problem earlier, Rest of the contents is wrong and specifically denied . It is wrong ad denied that the applicant was hospitalized for three days as alleged. It is wrong and denied that in admission of claim of applicant is due to negligence, carelessness of respondent as alleged. Hence complaint is not entitled for any claim and complaint of the complainant may kindly be dismissed with costs.
3. Complainant has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C12 and closed his evidence. Ld. counsel for OP closed the evidence after tendering the documents Annexure R1.
4. Arguments heard and filed perused.
5. At the outset we concur with the objections of the opposite party that the complaint is premature since there is no proof or any documents regarding repudiation of claim is not placed on the file by any party. As such we direct the complainant to submit the relevant documents as early as possible and further direct the opposite party that after receiving the relevant documents from the complainant, they shall take an appropriate decision within 30 days from the receipt of documents. Complaint is disposed of accordingly with the observation that in case the complainant is not satisfied with the decision of the opposite party, he shall be at liberty to file the fresh complaint. Original documents exhibits submitted by both the parties shall be returned to them and photocopy of the same be placed on record.
6. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced on: 21.12.2018 (Rajbir Singh Dahiya)
President
District Consumer Disputes
Redressal Forum, Nuh (Mewat).
(Urmil Beniwal)
Member
District Consumer Disputes
Redressal Forum, Nuh (Mewat).
