Before the District Consumer Disputes Redressal Forum, Rohtak.
Complaint No. : 271.
Instituted on : 13.06.2018.
Decided on : 13.11.2019.
Pardeep Kumar age 40 years, s/o Sh. Ramphal R/o VPO Gandhra, District Rohtak.
………..Complainant.
Vs.
Oriental Insurance Co. Ltd. through its Divisional Manager, Opp. D-Park, Rohtak.
……….Opposite party.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. RENU CHAUDHARY, MEMBER.
Present: Sh.Deepak Jain, Advocate for the complainant.
Sh.D.S.Chauhan Advocate for opposite party.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Present complaint has been filed by the complainant with the averments that he had obtained one oriental Royal Medi claim policy No.261200/48/2016/2834 from the respondent for the period 15.03.2016 to 13.03.2017 covering himself and his family. The complainant got the said policy renewed for the period 12.04.2017 to 11.04.2018 and again for the period 12.04.2018 to 11.04.2019. During the commencement of second policy i.e. policy no.261200/48/2018/161 the complainant underwent Coronary Artery Disease Treatment at the Holy Heart Hospital, Rohtak. He was admitted on 10.09.2017 and was discharged on 11.09.2017. The complainant has spent an amount of Rs.1 lakh on his treatment. The complainant submitted all the relevant bills at the office of respondent company as well as agent M/s Raksha health Insurance, Faridabad to claim medi-claim expenses. Complainant visited several times at the office of opposite party to get the claim amount. The complainant received a letter dated 25.01.2018 from the respondent company vide which he was informed that his claim has been repudiated on the ground of concealment of pre-existing disease. That complainant was not having any pre existing disease as alleged by the insurance company and the problem occurred suddenly. That the act and conduct of the opposite party in repudiating the claim of complainant is illegal and amounts to deficiency in service. Hence this complaint and it is prayed that opposite party may kindly be directed to pay the mediclaim expenses to the complainant as per bills issued by the Hospital alongwith interest from the date of operation till actual realization and also to pay Rs.50000/- as compensation to the complainant.
2. After registration of complaint, notice was issued to the opposite party. Opposite party in its reply has submitted that complainant has availed the Medi claim policy through agent Raksha Health Insurance TPA Pvt. Ltd. for a period 14.03.2016 to 13.03.2017 and 12.04.2017 to 11.04.2018. Complainant underwent Coronary Artery disease treatment at Holy Heart Hospital, Rohtak, admitted on 10.09.2017 and discharged on 11.09.2017. The complainant has not fill up correct information about his health status in the proposal form and declaration submitted by him. Complainant vide his letter dated 18.09.2017 has submitted treatment record in the office of Raksha Health Pvt. Ltd. and Raksha Health Pvt. Ltd. had sent the documents to the respondent office. After legal process of the claim, the respondent found that as per policy clause no.4.1, any ailment/disease injury/Health condition which are pre-existing( treated, non treated, declared or non declared in the proposal) in case of any of the insured person of the family, when the cover incepts for first time, are excluded for such insured person upto three years of the policy being enforce continuously. This exclusion will also apply to any complications arising from pre-existing ailment/disease and injuries. Such complications shall be considered as part of the pre-existing Health conditions of disease. In this case, the complainant underwent an angioplasty as policy running under two years. Therefore, the competent authority repudiated the claim of the complainant as No Claim, and intimation to the same was sent to the complainant vide letter dated 25.01.2018. The claim of the complainant has rightly been repudiated as per policy clause no.4.1. There is no deficiency in service on the part of respondent and dismissal of complaint has been sought.
3. Learned counsel for the complainant in his evidence tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C8 and has closed his evidence on dated 13.02.2019. Ld. counsel for the opposite party in his evidence has tendered affidavit Ex.RW1/A, documents Ex.R1 to Ex.R6 and closed his evidence on dated 30.05.2019.
4. We have heard learned counsel for the parties and have gone through the material aspects of the case very carefully.
5. After going through the file and hearing the parties it is observed that the claim of the complainant has been repudiated by the opposite party on the ground that the complainant underwent coronary artery disease treatment at Holy Heart Hospital, Rohtak, admitted on 10.09.2017 and discharged on 11.09.2017. The complainant has not fill up correct information about his health status in the proposal form and declaration submitted by him. After perusal of the document Ex.C4 at page no.2 of Patient history, it is revealed that : “Patient have a history of mild chest pain since 8-10 days. Now he is c/o severe chest pain radiating to back & both arm pain a/w sweating. Eco Shows VT. reverted with CPR”. In this regard it is observed that the date of admission of complainant in the hospital is 10.09.2017 and the date of ailment is 8-10 days before the admission i.e. near about 31.08.2017 whereas the period of policy is 12.04.2017 to 11.04.2018. Hence from the document it is not proved that complainant has not fill up correct information about his health status in the proposal form and declaration submitted by him. We have also perused list of diseases given at page no.10 of policy Ex.R5, and as per condition no.4.2 of the policy, it is submitted that “The expenses on treatment of following ailments/disease/surgeries, if contracted and/or manifested after inception of first policy(subject to continuity being maintained, are not payable during the waiting period specified below” and 23 ailments have been mentioned in the list. But the disease of the complainant is not mentioned in the alleged list of diseases. Moreover, no treatment record of complainant prior to commencement of policy has been placed on record by the opposite party. Hence from the documents placed on record by the opposite party, it is not proved that there was concealment of fact regarding ailment/disease of complainant. As such, opposite party is liable to pay the claim amount to the complainant. As per copy of bill Ex.C7, complainant had spent Rs.90000/- on his treatment.
6. In view of the facts and circumstances of the case, complaint is allowed and we hereby direct the opposite party to pay Rs.90000/-(Rupees ninety thousand only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 13.06.2018 till its realization and shall also to pay a sum of Rs.5000/-(Rupees five thousand only) as compensation as well as litigation expenses to the complainant within one month from the date of decision.
7. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
13.11.2019
…………………………………..
Nagender Singh Kadian, President
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Renu Chaudhary, Member.
