CONSUMER DISPUTES REDRESSAL FORUM – X

GOVERNMENT OF N.C.T. OF DELHI

Udyog Sadan, C – 22 & 23, Institutional Area

(Behind Qutub Hotel)

New Delhi – 110 016

Case No.401/2010

SH. SANDEEP KANOTRA

T-2, 1003 PARSHVNATH ESTATE,

KASNA ROAD, POCKET P-4,

GREATER NOIDA(U.P.)-201306

ALSO AT:-

HABITAT WORLD,

INDIA HABITAT CENTRE,

LODHI ROAD, NEW DELHI-110003

                                                         …………. COMPLAINANT                                                                                  

Vs.

1. RELIANCE GENERAL INSURANCE CO. LTD.,

RELIANCE CENTRE,

19, WALCHAND HIRACHAND MARG,

BALLARD ESTATE, MUMBAI

ALSO AT:-

RELIANCE GENERAL INSURANCE CO. LTD.,

(POLICY SERVICING BRANCH OFFICE)

PLOT NO.60, OKHLA INDUSTRIAL ESTATE,

PHASE-3, NEW DELHI

2. MEDI ASSIST INDIA PVT. LTD.,

3^RD FLOOR, NO.49, 1^ST MAIN ROAD, J.P. NAGAR,

SARAKKI INDUSTRIAL LAYOUT,

3^RD STAGE, BANGALORE-560078

ALSO AT:-

MEDI ASSIST INDIA PVT. LTD.,

F-2, KAILASH PLAZA, 2^ND FLOOR,

H-252, SANT NAGAR, EAST OF KAILASH,

NEW DELHI-110065

3. MOOLCHAND MEDCITY,

LAJPAT NAGAR-III,

NEW DELHI-110024

                                                          …………..RESPONDENTS

                                                                                         Date of Order:07.07.2017

O R D E R

A.S. Yadav - President

            The complainant took Health Insurance policy from OP-1 for the first time for the period 27.03.07 to 26.03.08 for a sum of Rs.5 lakhs.  The said policy was renewed for the period from 27.03.08 to 26.03.09 and the policy was further renewed for the period from 27.03.09 to 26.03.10. 

On 03.07.09 complainant was admitted to OP-3 hospital on account of sudden onset of Epigastric discomfort radiating to left arm with profuse sweating.  The complainant was admitted to “Shri Mool Chand Khairaiti Ram Hospital Ayurvedic Research Institute, Delhi on 03.07.09 with ailment of CAD, acute inferior wall MI, hypertension, metabolic syndrome, dyslipidemia and underwent surgery-PTCA+stenting to RCA(Yukon 3.5X24) and was discharged from the hospital on 13.07.09.  The complainant incurred expenses of Rs.3,79,265/-.

The complainant submitted his claim form to TPA i.e. OP-2 on 28.07.09 alongwith original documents pertaining to his treatment including the discharge summary.  The complaint sent numerous emails dated 21.09.09, 25.09.09, 06.10.09, 15.10.09, 29.10.09, 06.11.09, 09.11.09, 23.11.09, 03.12.09, 15.12.09, 16.12.09 and made numerous phone calls however the OP failed to respond to request of complainant for settlement of the claim.  Finally complainant received a communication dated 18.12.09 from OP-1 about the rejection of his claim on the ground that complainant has a previous history of alcoholism and hypertension.  The complainant vehemently denied existence of habit of alcoholism or medical condition of hypertension.  It is stated that the complainant was in a perfect state of health till the time he suffered his first heart attack on 03.07.09.  It is stated that the policy in question covers medical expenses incurred by the policy holder from the third year of the policy for treatment of “pre-existing diseases, illness, injury or condition”.  Without prejudice to the rights and conditions of the complainant, even if for the sake of arguments it is submitted that the complainant suffered heart-attack after three years of his purchasing the insurance, even if he suffered the same due to alcoholism or hypertension, even then the claim of complainant would clearly fall within the four corners of the terms and conditions prescribed in the policy. 

It is submitted that OP-1 denied the valid claim of complainant also on the ground of two discharge summaries.  It is submitted that discharge summary is prepared by OP-3 and is not in hands of the patient and complainant is not aware of that.  It is further submitted that complainant incurred expenditure of Rs.3,79,265/- during hospitalization and further  incurred expenses of Rs.15556.86 towards post hospitalization.  Complainant has prayed that OP be directed to pay a sum of Rs.3,79,265/- towards the hospitalization expenses and Rs.15,556.86 towards post hospitalization expenses alongwith interest and also pay compensation and litigation expenses.

OP-1 and OP-2 in reply took the plea that on the receipt of claim, the same was processed as per the policy and was referred for internal investigation to check the genuineness of the claim.  The case was investigated by the internal investigator who found the complainant to be a smoker, alcoholic and suffering from hypertension since two years.  However, complainant was not on medication for hypertension.  It was observed that discharge summary provided by the insured and the discharged summary available at the hospital records is varying and ailment details captured are contradictory from the discharge summary in record.  Complainant has suppressed the facts that he was suffering for hypertension which is the direct causative factor for ailment and the insured has not disclosed this fact at the time of taking of the policy hence has taken the policy fraudulently.  It is stated that there is no deficiency in service on the part of OP.  It is prayed that the complaint be dismissed.

OP-3, the treating hospital, denied that there were two discharge summaries prepared for complainant as alleged.  In fact prior to his discharge a brief note of medical treatment was prepared by the resident doctor for the ready reference of the consultant doctor who was treating the complainant.  The consultant doctor who attended him throughout his stay in the hospital, after perusing the note of resident doctor again examined the medical history and treatment record of the complainant and prepared the discharged summary, which was also seen by the resident doctor again and when they both got satisfied themselves only then they both i.e. resident doctor and consultant have signed this discharge summary and handed over to the complainant.  The note which was prepared by the resident doctor for the consideration of the consultant doctor who was attending the complainant cannot be treated as discharge summary as it was only a note of medical history of the complainant.  Therefore no error has been committed by OP-3.

We have heard Ld. Counsel for the parties and carefully perused the records. 

The sole ground for rejection of the claim was that complainant was suffering from hypertension and was smoker, and alcoholic.  Complainant has specifically stated that he was not suffering from hypertension and was not alcoholic.  In fact the onus was on the OP-2 to prove that in fact complainant was alcoholic and smoker.  OP has not placed anything on the record that he was alcoholic. 

It is not the case of OP-1 that complainant has been taking any medication for hypertension or he was hospitalized for hypertension.  Complainant has specifically stated that he was not suffering from hypertension.  Assuming for the sake of argument, that complainant was suffering from hypertension, it is an admitted fact that complainant was not taking any medicine for that.  Hypertension is a usual ailment from which most of the persons are suffering.  It cannot be ground for rejection of claim specially when there is nothing on the record to suggest that complainant was taking medicine for that or ever hospitalized for that.  It is significant to note that complainant has specifically stated in para 10 of his complaint that the policy in question covers medical expenses incurred by the policy holder from the third year of the policy for treatment of “pre-existing diseases, illness, injury or condition”.  Without prejudice to the rights of the complainant, it is significant to note that the complainant suffered heart-attack after three years of taking the insurance, even if it was on account of alcoholism or hypertension, even then the claim of complainant would clearly fall within the four corners of the terms and conditions prescribed in the policy.  This fact is not denied by OP-1 and OP-2 in reply. 

The policy was renewed for the third time.  The complainant was not suffering from pre-existing disease.  Even if he was suffering from hypertension even then as per the policy he is entitled for reimbursement.  There is no question of concealment of any fact.  OP-1 and OP-2 have miserably failed to prove that complainant was smoker, alcoholic and further failed to prove that there were two discharge summaries.  Repudiation of the claim was not justified.  It is a clear cut case of deficiency in service on the part of OP. 

OP-1 is directed to pay Rs.3,79,265/- towards the hospitalization expenses and Rs.15,556.86 towards post hospitalization to complainant alongwith interest @ 9% p.a. from the date of filing of complaint till realization.  OP is further directed to pay Rs.10,000/- towards compensation and Rs.5,000/- towards litigation expenses.

Let the order be complied with within one month of the receipt thereof.  The complaint stands disposed of accordingly.

Copy of order be sent to the parties, free of cost, and thereafter file be consigned to record room. 

     (D.R. TAMTA)                     (RITU GARODIA)                        (A.S. YADAV)

        MEMBER                               MEMBER                                  PRESIDENT