JUDGMENT 12.10.2010 Justice Pritam Pal, President 1. This appeal by New India Assurance Co. Ltd.- one of the opposite parties is directed against the order dated 20.8.2009 passed by District Consumer Forum-II, U.T. Chandigarh whereby complaint bearing No.682 of 2008 of respondent No.1(complainant) was allowed with costs of Rs.2500/- and appellant as well as respondent No.2 were directed to pay to the complainant insured amount of Rs.1,00,000/- alongwith compensation of Rs.50,000/-. These amounts were ordered to be paid within six weeks from the date of receipt of copy of the order, failing which OPs were made liable to pay the amount of Rs.1,50,000/- alongwith penal interest @ 18% p.a. from 2.7.2007 till its realization besides costs. 2. The parties hereinafter shall be referred to as per their status before the District Forum. 3. In nutshell, the facts as set out in the complaint are that in the year 2005, OPs induced the Complainant by giving on offer through CITI Bank Gold Credit Card for getting the medi-claim policy which was accepted by the complainant and he was insured to the tune of Rs.1.00 lac against any hospitalization expenses and insurance ID was issued to him. During the first year of the policy, no claim was taken by the complainant. After one year, the OP again contacted the Complainant for renewal of the policy to which he agreed and paid the premium . On 16.01.2007, due to some lungs infection, the Complainant was admitted to Silver Oaks Hospital, Mohali. Immediately one authorization letter was faxed to OPs for claiming the insured sum but no reply was received by the complainant or hospital authorities. The condition of the complaint became more serious and he was shifted to Fortis Hospital for treatment on 17.1.2007. The condition of the complainant went on deteriorating and a fax message was again sent to the OP but no approval was given. The complainant remained admitted in the ICU of Fortis hospital as his both lungs had collapsed due to Pneumonia and he remained on ventilator for 40 days. The total bill of his hospitalization was Rs.6,40,000/- approx., which was paid to the hospital authorities. During this period, the family members of the complainant tried to contact OP but they never responded back. Ultimately, the complainant paid the amount from his own sources by taking a loan from friends and relatives. After discharge from the hospital, the complainant wrote letters to the OP upon receipt of which, they sent two forms through courier service and demanded original bills pertaining to his treatment and medicines etc. alongwith detailed summary of the treatment. Accordingly the claim form was duly filled by the Complainant and same was sent to the OP along with original bills. However, after few days they again sent one letter and demanded NOC for verifying the treatment from the hospital and also sent some documents, which were to be filled in by the hospital authorities regarding the treatment of the Complainant. Despite completing all formalities OPs did not settle the claim. The complainant then sent letter dated 02.07.2007 requesting OPs to reimburse the amount but to no effect. Hence, alleging deficiency in service on the part of OPs, complainant filed complaint before the District Forum. 4. The case of OP NO.1 before the District Forum was that on receiving fax message from the complainant on 17.1.2007 with regard to his undergoing treatment, OP NO.1 refused the cashless treatment on account of possibility of long standing pathology vide fax dated 20.1.2007. The complainant was provisionally diagnosed and having Pickwikian’s Syndrome with acute renal failure and as such the case of complainant was required to be thoroughly investigated before permitting reimbursement. The complainant was requested to give certain detail but he failed to clear the said queries inspite of repeated reminders, thus, the file of the complainant was closed as the only discharge summary from the Fortis Hospital, Mohali did not answer to the queries of OP NO.1. So, it was pleaded that there was no deficiency in service on its part and a prayer was made for dismissal of the complaint. Similar reply was filed by OP NO.2 taking identical pleas. 5. The District Consumer Forum after going through the evidence and hearing learned counsel for the parties allowed the complaint as indicated in the opening part of this judgment. 6. We have heard learned counsel for the parties and gone through the file carefully. The main point of arguments raised on behalf of the appellant/OP was that as per the diagnosis made by the expert doctors of the Fortis Hospital as well as the third party Administrator i.e. TTK Health Care Service Pvt. Ltd the insured was suffering from “ Pickwiaians Sydrome with acute renal failure 4D for medical management, HO DM/HT 2 years”, thus possibility of long standing pathology was felt and hence, cashless facility was denied as the claim was not payable. The complainant was asked to submit all the documents in original and also give other information/documents but complainant did not bother to submit the relevant information either to the insurance company or to TTK Healthcare Services Pvt. Ltd. Further, the insured had concealed the material facts as he was suffering from the disease even before the inception of insurance policy, the whole contract stood vitiated and complainant was not entitled to any claim or compensation. He further submitted that the award of compensation as well as penal interest is on the higher side. However, learned counsel for complainant repelled the aforesaid arguments. 7. It is an admitted fact that the medi-claim policy was obtained by the complainant in the year 2005 for a sum of Rs.one lac against any hospitalization expenses and insurance ID card was issued to him. The said policy was then again renewed for another year. There is no evidence that complainant had pre-existing disease or even if he was having pre-existing disease then complainant was having knowledge that he was suffering from the disease Pickwiaians Syndrome with acute renal failure before the inception of the insurance policy and he did not disclose the same at the time of insuance. On 16.1.2007 due to some lungs infection complainant was admitted in the Hospital. There is no evidence that complainant had earlier taken treatment for the said disease and remained admitted in any hospital. The complainant has submitted all the requisite documents and also NOC in the prescribed proforma vide his letter dated 2.7.2007. Thus, the District Forum rightly allowed the claim for the sum assured of Rs.one lac. In the given facts and circumstances of the case the compensation amount appears to be justified as it includes interest also. So far as award of penal interest @ 18% is concerned that was in the case of failure of OP to pay the amount within the stipulated period, hence there is no justification in reducing the same. 8. In view of the above discussion, we are of the opinion that there is nothing wrong in the impugned order passed by the learned District Forum. Thus, the appeal fails and is hereby dismissed, leaving the parties to bear their own costs. Certified Copies of this order be sent to the parties, free of charge. The file be consigned to record room.
| | HON'BLE MRS. NEENA SANDHU, MEMBER | HON'BLE MR. JUSTICE PRITAM PAL, PRESIDENT | HON'BLE MR. JAGROOP SINGH MAHAL, MEMBER | |
