DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA CC.No.509 of 03-11-2010 Decided on 02-05-2011
Sandeep Garg son of Sh.Madan Lal Garg, aged about 36 years, resident of H.No.5147, Cozy Home, Nai Basti, Gali No.6, Bathinda. .......Complainant
Versus Reliance General Insurance Co. Ltd., 570, Naigaon Cross Road, Next to Royal Industrial Estate, Wadala (W), Mumbai-400031, through its M.D./ Chairman. Reliance General Insurance Co. Ltd., 7th Floor, Surya Towers, 108, The Mall, Ludhiana, Punjab, through its Authorized Representative. Reliance General Insurance Co. Ltd., Reliance Office, Prime Time, SCO-5, Ahata Pritam Singh Sidhu, Amrik Singh Road, Bathinda, through its Manager.
......Opposite parties
Complaint under Section 12 of the Consumer Protection Act, 1986.
QUORUM
Smt. Vikramjit Kaur Soni, President. Dr.Phulinder Preet, Member. Sh.Amarjeet Paul, Member. Present:- For the Complainant: Sh.Vikas Singla, counsel for the complainant. For Opposite parties: Sh.J.D.Nayyar, counsel for opposite parties.
ORDER
VIKRAMJIT KAUR SONI, PRESIDENT:-
1. The present complaint has been filed by the complainant under Section 12 of the Consumer Protection Act, 1986 as amended up-to-date (Here-in-after referred to as 'Act'). The brief facts of the complaint are that the complainant had purchased Medical Insurance Policy of Reliance General Insurance Co. Ltd. bearing Policy No.2001/792825005713 in his name for the period from 10.07.2009 to 09.07.2010 after depositing the premium amount of Rs.5,594/- under Gold Plan with Sum Assured of Rs.3 Lacs. As per the terms and conditions of the Policy, the complainant, his wife Rekha Garg and children namely Ankit Garg and Pushpa Garg are covered under the said Policy. The complainant fell ill due to Acute Febrile Illness and Hepatitis and was got admitted in Deep Multi/Super Specialty Hospital, Bathinda on 18.10.2009 and remained admitted till 25.10.2009. He took the treatment in the said hospital and spent Rs.43,291/- for his treatment including Doctor/Nursing Fee, Medical bills, Patholigical Lab Expenses, Daily Hospitalization allowance and other misc. expenses. The complainant lodged the claim with the opposite parties vide claim No.4500554 for a sum of Rs.43,291/- and the opposite parties also put query regarding the said claim vide letter dated 10.12.2009 and demanded certain documents. The complainant furnished all the requisite formalities to honour the lawful claim of the complainant including original bills and documents which are also in possession of the opposite parties. The claim of the complainant has been repudiated by the opposite parties vide letter dated 07.04.2010. Thereafter, the complainant again fell ill on 05.05.2010 due to the Acute pain in the abdomen, vomiting and high grade fever and he was taken to Deep Multi Super Specialty Hospital, Bathinda on 05.05.2010 and was admitted in I.C.U. The complainant was diagnosed by the Doctors and it was revealed that he was suffering from acute pancratitis. The complainant again remained admitted in the said Hospital from 05.05.2010 to 14.05.2010 and took the treatment from the aforesaid hospital and spent Rs.89,319/- for his treatment including hospital charges and medicines. Thereafter, he lodged the another claim with the opposite parties vide Claim No.5046513 and supplied all the requisite documents to the opposite parties for reimbursement of the abovesaid amount of medical expenses borne by him for his treatment alongwith original bills of medicines and other treatment record which is already in possession of the opposite parties. The opposite parties vide their letter dated 19.06.2010 asked the complainant to complete certain formalities which were completed by him despite that the opposite parties have failed to settle the claim of the complainant and have not paid even a single penny to the complainant rather the opposite parties vide their letter dated 31.08.2010 have repudiated the claim. The complainant has pleaded that he has never concealed the material facts from the opposite parties in the Proposal Form or in the personal statement etc. at the time of purchasing the medical insurance policy as alleged by the opposite parties in the said repudiation letter. The complainant also got a legal notice upon the opposite parties on 29.09.2010 but the opposite parties did not give any reply to the said notice. Hence, the complainant has filed this complaint to seek directions to the opposite parties to reimburse the insurance claim of Rs.43,291/- and Rs.89,319/- alongwith cost and compensation. 2. The opposite parties have filed their joint written statement and admitted the fact that the complainant had obtained a medical insurance policy from the opposite parties and the claim with regard to the same if any was payable as per the rules and regulations and as per terms and conditions of the Policy. The opposite parties had received information from the complainant regarding his falling ill and the complainant had filled in the claim Form bearing claim No.4500554. The complainant had been asked to complete the requisite formalities which included the required documents so that the same could be scrutinized. On scrutinizing the case of the complainant, it was found that the claim was not payable due to the following reasons :- “Exclusion Clause No.1 Pre-existing diseases/illness/injury/conditions which are pre-existing when he cover incepts for the first time. Condition Clause No.2. Duty of disclosure – The Policy shall be null and void and no benefit shall be payable in the event of untrue or incorrect statements, misrepresentation, misdescription or non-disclosure of any material particulars in the Proposal Form, personal statement, declaration and connected documents or any material information having been withheld, .......under the policy.” The opposite parties have further pleaded that on perusing the documents supplied by the complainant, it was found that the patient was admitted at Deep Multi Specialty Hospital for the treatment of fever with Hepatitis on 18.10.2009 and was discharged on 25.10.2009. As per claim Investigation performed, it is evidence that the claimant was suffering from the ailment Hepatitis for the last 2 years and on irregular medications for the same. This particular disease found to be present prior to the inception of policy and admit their inability to pay the claim under the present policy. Thereafter, again the opposite parties had received information from the complainant regarding his falling ill. The complainant had filed the claim Form bearing No.5046523. The complainant had been again asked to complete the requisite formalities which included the submission of the required documents so that the same could be scrutinized. On scrutinizing the case of the complainant, it was found that the claim was not payable due to the following reasons :- “Condition Clause No.2. The Policy shall be null and void and no benefit shall be payable in the event of untrue or incorrect statements, misrepresentation, misdescription or non-disclosure of any material particulars in the Proposal Form, personal statement, declaration and connected documents or any material information having been withheld,........under the policy. Condition Clause No.15 If any claims is in any respect fraudulent or if any false statement or declaration is made or used in support thereof, or if any fraudulent means or devices are used by the insured person or anyone acting on his/her behalf to obtain any benefit under this policy or .........all benefits under this policy shall be forfeited.” It was found that the claimant was admitted at Deep Hospital for the treatment of Acute Pancreatitis on 05.05.2010 and discharged on 14.05.2010. As per claim Investigation performed following observation were made :- 1. As per patients statement, he had fever, pain abdomen and vomiting and had fainted prior to Hospitalization. However, there is no mention of loss of Consiousness in IPD Records of Hospital. 2. The patient was admitted in ICU for 5 days, however there is no vitals charting done during the entire period of Hospitalization in spite of Severity of pertinent Condition. 3. Injection Linezolied was advised on BD basis on 06.05.2010, however was not administered. Injection Alamin, Injection Merospa and Injection Linezolied was advised on 11.05.2010. They were administered on 10.05.2010 before doctors prescription. The patient was administered 2 doses of merospan on 13.05.2010. As per the treatment chart, the patient was administered medicines at 11.20 am. The claim of the complainant was repudiated under condition 2 and 15. Two separate claims of the complainant were looked into and both the claims had been repudiated vide two different letters of repudiation. The details and the reason for the repudiation had been clearly mentioned in the repudiation letters which were self explanatory. 3. Parties have led their evidence in support of their respective pleadings. 4. Arguments heard. Record alongwith written submissions submitted by the parties perused. 5. The complainant is holding Reliance Medical Insurance Policy bearing No.2001/792825005713 w.e.f. 10.07.2009 to 09.07.2010. He paid the premium amount of Rs.5,594/- under Gold Plan with Sum Assured of Rs.3 Lacs. As per the terms and conditions of the Policy, the complainant, his wife and children are covered under the said Policy. The complainant fell ill due to Acute Febrile Illness and Hepatitis and was got admitted in Deep Multi/Super Specialty Hospital, Bathinda on 18.10.2009 and remained admitted till 25.10.2009 and spent Rs.43,291/- for his treatment including Doctor/Nursing Fee, Medical bills, Patholigical Lab Expenses, Daily Hospitalization allowance and other misc. expenses. He lodged the claim vide claim No.4500554 for a sum of Rs.43,291/-. The opposite parties put query regarding the said claim vide letter dated 10.12.2009 and required certain documents and accordingly, the complainant furnished all the requisite formalities including original bills and documents but the opposite parties have repudiated the claim of the complainant vide letter dated 07.04.2010. Thereafter, the complainant again fell ill on 05.05.2010 due to the Acute pain in the abdomen, vomiting and high grade fever and he was taken to Deep Multi Super Specialty Hospital, Bathinda on 05.05.2010 and was admitted in I.C.U. The complainant was diagnosed by the Doctors, suffering from acute pancratitis. He again remained admitted in the said Hospital from 05.05.2010 to 14.05.2010 and took the treatment from the aforesaid hospital and spent Rs.89,319/- for his treatment including hospital charges and medicines. Thereafter, he lodged the another claim vide Claim No.5046513 and supplied all the requisite documents to the opposite parties for reimbursement of the said amount of medical expenses alongwith original bills of medicines and other treatment record. The opposite parties vide their letter dated 19.06.2010 asked the complainant to fulfill certain formalities which were completed by him but despite that the opposite parties have failed to settle the claim of the complainant and have not paid even a single penny to the complainant. The opposite parties vide their letter dated 31.08.2010 have repudiated the claim of the complainant on the ground that the complainant has concealed the material facts from the opposite parties. 6. Admitted facts of the parties that the complainant is holding Reliance Medical Insurance Policy bearing No.2001/792825005713 and the opposite parties have received intimation regarding his following illness through claim Forum No.4500554. The complainant completed all the formalities with regard to his claim. Thereafter, he again lodged a claim vide claim No.5046513. The opposite parties have repudiated both the claims of the complainant on the ground that the exclusion clause 1 and condition No.2 are applicable on the complainant in case of his first claim. Under this clause, he is not entitled for any claim as he has suppressed the material facts that he is suffering from the ailment Hepatitis for the last 2 years and on irregular medications for the same. Therefore, this particular ailment is found to be present prior to the inception of policy and going beyond the coverage of present policy and repudiated the claim of the complainant. He remained admitted in the hospital for the treatment from 18.10.2010 and discharged on 25.10.2010. Regarding second claim, the opposite parties repudiated the claim of the complainant on condition clause No.2 and Condition clause No.15 on the ground that the complainant was taking the treatment on Acute Pancereatitis on 05.05.2010 and discharged on 14.05.2010. As per investigation, the patient was suffering from fever, pain abdomen and vomiting and had fainted prior to Hospitalization. There is no mention of loss of Consiousness in IPD Records of Hospital. The patient was admitted in ICU for 5 days, however there is no vitals charting done during the entire period of Hospitalization in spite of Severity of pertinent Condition. Injection Linezolied was advised on BD basis on 06.05.2010, he was not administered. Injection Alamin, Injection Merospa and Injection Linezolied was advised on 11.05.2010. However, they were administered on 10.05.2010 before doctors prescription. Further, the patient was administered 2 doses of merospan on 13.05.2010. As per the treatment chart, the patient was administered medicines at 11.20 am. Both the claims of the complainant were repudiated vide two different letters of repudiation. The details and the reason for the repudiation had been clearly mentioned in the repudiation letters. 7. A perusal of Ex.C-6 with regard to claim No.4500554 shows that the claim of the complainant has been repudiated on the following ground that :- Clause Description Exclusion 1. Pre-existing diseases/illness/injury/conditions which are pre-existing when he cover incepts for the first time. Condition 2. Duty of disclosure – The Policy shall be null and void and no benefit shall be payable in the event of untrue or incorrect statements, misrepresentation, misdescription or non-disclosure of any material particulars in the Proposal Form, personal statement, declaration and connected documents or any material information having been withheld, .......under the policy........”As per claim investigation performed it is evident that the claimant was suffering from the ailment Hepatitis for the past 2 years and or irregular medications for the same. Therefore, this particular ailment is found to be present prior to the inception of policy and going beyond the coverage of present policy. Hence, we regret our inability to admit this liability under the present policy conditions and claim is being repudiated under policy exclusion clause 1 and condition No.2 of above mentioned policy. We also reserve the right to repudiate the claim under any other grounds available to us subsequently.” According to the complainant, he was suffering from Acute Febrile Illness and Hepatitis but his claim has been repudiated on the ground that he has been suffering from the ailment Hepatitis for the past 2 years. 8. Further Ex.C-11 shows that the second claim No.5046513 was repudiated on the following ground that :- Clause Description Condition 2 The Policy shall be null and void and no benefit shall be payable in the event of untrue or incorrect statements, misrepresentation, misdescription or non-disclosure of any material particulars in the Proposal Form, personal statement, declaration and connected documents or any material information having been withheld,........under the policy. Condition 15 If any claims is in any respect fraudulent or if any false statement or declaration is made or used in support thereof, or if any fraudulent means or devices are used by the insured person or anyone acting on his/her behalf to obtain any benefit under this policy or .........all benefits under this policy shall be forfeited.” “It was found that the claimant was covered under the above mentioned policy was admitted at Deep Hospital for the treatment of Acute Pancreatitis on 05.05.2010 and discharged on 14.05.2010. As per claim Investigation performed following observation were made :- 1) As per patients statement, he had fever, paid abdomen and vomiting and had fainted prior to Hospitalization. However, there is no mention of loss of Consiousness in IPD Records of Hospital. 2) The patient was admitted in ICU for 5 days, however there is no vitals charting done during the entire period of Hospitalization in spite of Severity of pertinent Condition. 3) Injection Alamin was not advised however was administered on BD basis on 06.05.2010, Injection Tramadol wa advised on BD basis on 06.05.2010 however was not administered. Injection Alamin, Injection Linezolied was advised on 11.05.2010. However, they were administered on 10.05.2010 before doctors prescription. Further, patient was administered 2 doses of merospan on 13.05.2010. However, he had purchased only 1 dose. 4) As per patient statement he was admitted at 6.30 pm on 05.05.2010, however as per the treatment chart, the patient was administered medicines at 11.20 am. Hence, we regret our inability to admit this liability in view of the above stated facts under the present policy conditions. Therefore, this claim is being repudiated under condition 2 and 15 and the same is not payable. We also reserve the right to repudiate the claim under any other ground available to us subsequently.” 9. Again the second claim of the complainant was repudiated. The statement of the Treating Doctor J.S.Sandhu Ex.C-10 which is reproduced as under:- “This is certify that Mr.Sandeep Garg S/o Madan Lal Garg aged 36 years having policy of your company and claimed to you against this policy. He was admitted in our hospital on 05.05.2010 with the complaints of Pain Abdomen, Vomiting, fever since 2 days as per Clinically Examination Ultra Sound findings and Blood Investigation Reports that Final Diagnosis was Acute Pancreatitis. As per your company letter answer of question (2) we have moniter vitals of our patients. We enclosed with letter, answer of question (2) Astymin Hepa was substitute of Alamin SN and injection Tramado injection Merospan injection linezolied was advised and there was clerical mistake under the treatment chart, answer of question (4) He was admitted in our hospital on 05.05.2010 time 11:20 am and discharged on 14.05.2010 satisfied. I, Dr. Jugraj Singh Sandhu, MS Surgeon Declare that Mr. Sandeep Garg s/o Madan Lal Garg, aged 36 years. He was admitted and treated by me.” This certificate shows that the complainant has been admitted in the hospital i.e. Deep Multi Super Specialty Hospital, on 05.05.2010 to 14.05.2010 for treatment of Acute Pancreatitis. 10. A perusal of both these certificate and Medical record placed on file shows that both time, the complainant was admitted in the hospital for 2 different problems, not with the same problem. Further, as per Ex.R-9 findings during verification/investigation, the opposite parties found that the problems with regard to the complainant's ailment were same as mentioned by the complainant himself and Dr.J.S.Sandhu. Therefore, there is no concealment of the facts regarding the health of the complainant. A perusal of Ex.R-12 i.e. Discharge Summary which is reproduced as under :- “Patient was admitted in ICU on 05.05.2010 with history of acute upper abdominal pain since 1 day. Pain was severe in nature rediating to back. Pain was associated with vomiting. Pain was not relieved with any oral medication. Patient had history of vomiting, projectile in nature. There was fever since 1 day, high grade with rigor and chills. There was no h/o any drug allergy, No H/o diabetes, hypertension. There was no h/o of alcoholism or smoking. On examination per abdominally, tenderness, gurarding rigidity was positive on upper abdomen. There was abdominal distension. Bowel sound were absent. Patient was investigated. TLC was raised. S Amylaase was raised to 1130 U/L. Ultrasound examination revealed acute pancreatitis. Patient was conservatively managed, kept nil per orally. Vitals monitored Ryle, stube aspiration done. 1Hourly intake/output maintained through. I.V.fluid according to the urinary output, Fever and pain subsided gradually. Patient was started orally on day 6th with liquid diet only. Patient was discharged on 14.05.2010 to follow up in OPD.” This discharge summary again shows that there was no pre-existing disease to the complainant at the time of filing the first claim vide claim No.4500554 and at the time of filing the second claim vide claim No.5046513. The opposite parties have wrongly repudiated the claim of the complainant on false grounds. Further, a perusal of Ex.C-18 i.e. Reliance General Insurance Policy shows that the complainant alongwith his family is covered after 2nd year renewal and the Policy is for Rs.3 Lacs. The complainant has not claimed any amount in previous policies. If, he had concealed the material fact regarding his pre-existing disease, he must have claimed the claim much earlier prior to this, where no such allegations are levelled on the complainant by the opposite parties. 11. In view of what has been discussed above, there is deficiency in service on the part of the opposite parties. Hence, this complaint complaint is accepted with Rs.5,000/- as cost and compensation against the opposite parties and the opposite parties are directed to reimburse the amount of Rs.43,291/- vide claim No.4500554 and Rs.89,319/- vide claim No.5046513 to the complainant. The total claimed amount payable to the complainant is Rs.1,32,610/- Compliance of this order be done within 45 days from the date of receipt of copy of this order. In case of non compliance of this order, interest @ 9% p.a. will yield on the insurance amount i.e. Rs.1,32,610/- till it realization. 12. A copy of this order be sent to the parties concerned free of cost and file be consigned for record. '
Pronounced in open Forum 02-05-2011 (Vikramjit Kaur Soni) President
(Dr.Phulinder Preet) Member
(Amarjeet Paul) Member
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