DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA

CC.No.307 of 14-11-2018

Decided on 13-06-2019

1.Mrs.Manjeet Kaur W/O Dr.Mohinder Singh aged about 62 years;

2.Dr.Mohinder Singh S/o Tulsa Singh aged about 63 years;

Both residents of # 642, Model Town, Phase-I, Bathinda, Puinjab-151001.

........Complainants

Versus

1.The Religare Health Insurance Company Limited; Corporate office: Vipul Tech Squire, Tower-C, 3rd Floor, Golf Course Road, Sector 43, Gurgaon-122009 (Haryana), through its M.D/G.M.

2.The Religare Health Insurance Company Limited; Golden Piaza Mall, 1st Floor, Mall Road, Ludhiana, Punjab, PIN Code-141001, through its Branch Manager/Head.

3.Indusind Bank, Guru Kanshi Marg, G.T. Road, Bathinda, through its Branch Manager.

.......Opposite parties

Complaint under Section 12 of the Consumer Protection Act, 1986

QUORUM

Sh.M.P Singh Pahwa, President.

Smt.Manisha, Member.

Present:-

For the complainant: Sh.Gaurav Vinocha, Advocate.

For opposite party Nos.1 & 2: Sh.Varun Gupta, Advocate.

For opposite party No.3: Sh.Sanjay Goyal, Advocate.

ORDER

M.P Singh Pahwa, President

1. The complainants Mrs. Manjeet Kaur and other (here-in-after referred to as complainants) have filed complaint U/s 12 of Consumer Protection Act, 1986 against opposite parties The Religare Health Insurance Company Limited and Others (here-in-after referred to as opposite parties).

2. Briefly, the case of the complainants is that they are husband and wife. They were holder of Health Insurance Policy, Primary Insured Policy bearing No.10238909. They got renewed this policy from time to time having validity period up to 25.3.2017 with cashless treatment facility upto treatment of Rs.5 lakhs. The policy was issued by opposite party Nos.1 and 2 through opposite party No.3 at Bathinda. The policy was sold to the complainants by opposite parties after making tall promises/facilities and allured by the same, the complainants purchased the policy through agent at Bathinda. The agent got signatures of the complainant Dr.Mohinder Singh on blank printed forms and vouchers etc. without explaining anything to him and other beneficiaries and he signed the same in good faith. After making payment of premium for purchase of 'Health Insurance Policy', only a card was issued to the complainants. No detailed policy or any other document was issued to the complainants either at the time of issuing primary policy or at the time of renewing it.

3. It is alleged that during validity period of 'Health Insurance Policy', the complainant Manjit Kaur had to go to United State of America and on 13.1.2017, she was at International Air Port at New Delhi. She all of sudden suffered palpitation. She was immediately taken to Paras Hospital, Sushant Lok Phase-I, Sector 43, Gurgaon (now known as Guru Gram) Haryana, for treatment. She remained admitted there for treatment from 13.1.2017 to 15.1.2017. At the time of admission, this hospital was on the panel of authorized hospitals of opposite party Nos.1 and 2.

4. It is further alleged that after request for pre-authorization of cashless hospitalization of the complainant Manjeet Kaur, request was declined by opposite party Nos.1 and 2 vide their letter dated 15.1.2017 and reason for denial was as under:-

   “As per submitted documents, pay-ability of the case cannot be ascertained at this time. Hence, liability of insurer cannot be taken at present juncture and cashless facility is being denied. Please file for reimbursement with all supportive documents. Other documents.”

5. It is further alleged that the complainants paid bill of Rs.49,341/- raised by hospital for treatment of complainant Manjeet Kaur. Accordingly, she was discharged on 15.1.2017. On 23.1.2017, the complainant Dr.Mohinder Singh submitted the claim form with opposite party No.1 raising reimbursement of Rs.49,341/- spent on treatment of Insured Manjeet Kaur W/o Dr.Mohinder Singh. Opposite party No.1 registered claim as claim No.9030610400 pertaining to Health Insurance Policy No.#10238909. On 25.2.2017, opposite party No.1 has written letter to the complainant Dr.Mohinder Singh. In response to letter of opposite parties, the complainant Dr.Mohinder Singh sent complete indoor papers to opposite parties as per their requirement on 16.3.2017 with further submission that there is no past history of illness and treatment records and it was first episode with his wife i.e. insured Manjit Kaur. Letter-cum-reply dated 16.3.2017 was received by the concerned official of opposite parties on 21.3.2017 by acknowledging the same and putting his signature at the back of the copy of referred letter-cum-reply. Thereafter opposite party Nos.1 and 2 vide its letter dated 6.4.2017 rejected the claim of the complainants due to the reason of non-disclosure of material facts/pre-existing ailments at the time of proposal.

6. It is alleged that the rejection of claim letter is wrong, illegal and against law and facts. The insured Manjit Kaur was not having any past history of illness and treatment records suffered and treated to her by Paras Hospitals, Gurgaon as is clear from discharge summary issued by hospital wherein it is specifically mentioned that patient is not known case of any chronic illness and same get further strength that during treatment, all tests conducted on the person of insured-complainant-Manjit Kaur were found normal. There is no nexus of alleged previous chronic ailment suffered by insured-complainant-Manjit Kaur with the disease for which she was admitted and treated at hospital, which (Palpitation) happened all of sudden at Air-port New Delhi.

7. It is also alleged that even otherwise, the complainants have not been provided copy of any proposal form, terms and conditions of insurance policies purchased by them except health cards and accompanied with welcome letter. As such, they are not bound by the same. In this way and in the alternative also, rejection of claim regarding reimbursement of the bill of treatment is wrong, false, baseless, against law and facts and amounts to unfair trade practice.

   On this backdrop of facts, the complainants have alleged that they have suffered from mental tension and harassment. For these sufferings, they have claimed damages/compensation to the tune of Rs.25,000/- in addition to Rs.49,341/- alongwith interest @ 12% per annum and cost of litigation to the tune of Rs.11,000/-. Hence, this complaint.

8. Upon notice, opposite parties appeared through their counsel and contested the complaint by filing written version. In their joint written version, opposite party Nos.1 and 2 have pleaded that they are company duly incorporated under the Companies Act, 1956, having its Corporate office at Vipul Tech Square, Tower C, 3rd Floor, Golf Course Road, Sector-43, Gurgaon- 122009 (Haryana) and is providing Health Insurance Services.

   Thereafter opposite party Nos.1 and 2 have raised preliminary objections that this complaint is not maintainable. The complainants have attempted to misguide and mislead this Forum. They have suppressed the material facts with regard to pre-existing disease before purchase of the policy. However, it is admitted that opposite party Nos.1 and 2 issued policy on 21.3.2015 to 20.3.2016 covering the policyholder, his spouse and his son for a sum assured Rs.7,00,000/-. This policy was further renewed for year 2016-2017 subject to policy terms and conditions. On investigation of the documents, it is revealed that the complainant namely Manjeet Kaur concealed her earlier disease i.e Hypertension, Diabetes Mellitus and Cervical Spondylitis. The non-disclosure was vital as the insured was under a bounden duty to disclose the true and correct facts regarding medical history as the same was important to underwrite the correct risk in issuance of the policy. By not disclosing the true and correct facts by the assured, she took away the right of opposite party Nos.1 and 2 to underwrite the policy and induced them to issue the policy on false and incorrect information. Had the true and correct facts been known to opposite party Nos.1 and 2, the policy would have been issued on a different terms and conditions or would not have been issued to the insured. The complainants were well aware about the true and correct facts and still have chosen to hide the same from this Forum. As such, the complaint is liable to be dismissed.

9. Further preliminary objections are that the complaint is not maintainable in its present form as it involves disputed question of facts. These cannot be determined in summary jurisdiction. The complaint has been filed with malafide intention. The complainants have not come before this Forum with clean hands. That prima-facie no cause has arisen in favour of the complainants to file this complaint as their claim do not fall within the insurance as granted. The intricate questions of law and facts are involved in the matter in issue. The parties should have to lead evidence by examining the witnesses and other party would have to cross-examine the witnesses. The matter involved in this case cannot be decided in summary manner. The complainants, if so advised, may approach the civil court. The complaint is false, frivolous and vexatious in nature. As such, the complainants are liable to pay penalty under 'Act'. They are estopped from filing this complaint by their own acts, conduct, omissions and acquiescence.

10. Thereafter opposite party Nos.1 and 2 have given the brief facts stating that every proposer applies for policy by means of an application in the form of a customized proposal form (PF) wherein the proposer is required to fill-in material information in this form. Opposite party Nos.1 and 2 received duly filled and signed PF from the complainant Dr.Mohinder Singh for availing health insurance policy seeking to cover himself, his spouse and his son. Believing the information and details provided by the proposer including medical history in the proposal form to be true and correct in all respect and giving due credence to the under writing norms of opposite party Nos.1 and 2, policy bearing No.10238909 was issued for sum assured of Rs.7,00,000/- opted as per proposal form to the proposer for the period between 21.3.2015 to 20.3.2016 and further renewed for year 2016-2017 (Ordinary) rates of premium. The copy of schedule bearing relevant details of the policy alongwith policy bond having terms and conditions were duly sent and delivered to the proposer. No assurance was given to the complainants beyond terms and conditions of the policy. The policy kit containing all relevant documents was duly delivered to the complainants thereby giving an opportunity to them to verify and examine the benefits, terms and conditions of the policy, but they never approached opposite party Nos.1 and 2 stating that any information given in the policy schedule was incorrect.

11. It is further pleaded that the claim under the policy firstly received from the hospital for cashless treatment. The insured was admitted from 13.1.2017 till 15.1.2017 at Paras Hospital, Gurgaon for the treatment of Palpitation. She was diagnosed with Atrial Fibrillation, which is an irregular often rapid heart rate that commonly causes poor blood flow. She applied for the cashless facility request for the hospitalization bearing cashless claim No.80103361. On receiving this cashless request, opposite party Nos.1 and 2 vide letter dated 14.1.2017 sought for all previous treatment record related to present ailment and its exact duration and if there is any past history related to present ailment. On receiving the documents, opposite party Nos.1 and 2 denied the insured's cashless request on the ground that as per the submitted documents, pay-ability of this case cannot be taken at present juncture and cashless facility is being denied. Please file for reimbursement with all supportive documents. It was communicated to the concern hospital vide letter dated 15.1.2017.

    It is further mentioned that on post denial of the cashless facility request, the insured filed for reimbursement claim for the hospitalization vide claim No.90306104. On receiving the claim reimbursement, opposite party Nos.1 and 2 vide letter dated 25.2.2017 sought for all past records related to Artial Fibrillation and complete indoor case papers with admission notes, history sheet, notes and vital chart. Opposite party Nos.1 and 2 simultaneously triggered the claim investigation in order to check the veracity of the claim. On receiving the documents from insured and investigation done, opposite party Nos.1 and 2 observed that there is a misrepresentation of fact or concealment of fact related to the actual heath history of the insured, which was not disclosed at the time of inception of policy. The insured had a history of hypertension since 3 years, which is prior to the inception of the policy. As such, opposite party Nos.1 and 2 rejected the reimbursement claim of the insured under Clause 6.1 of the policy terms and conditions for non-disclosure of material information. The same was duly communicated to the insured vide letter dated 16.4.2017.

12. It is also unfolded that on receiving the documents, opposite party Nos.1 and 2 came up with following observations:-

    As per the statement given by Dr.Sunita Gupta who initially checked the insured and referred her to Paras Hospital. Gurgaon states that the insured is hypertensive since 3 years. The doctor has also stated the insured first consulted her 3 years back with complaint of swelling in legs, which was due to hypertension only. The insured is hypertensive since 3 years, was not disclosed to opposite party Nos.1 and 2 at the time of inception of policy.

    As per nursing assessment sheet issued by Paras Hospital, Gurgaon, the insured has a past history of Hypertension, Diabetes Mellitus and Cervical Spondylitis, which was not disclosed to opposite party Nos.1 and 2 at the time of inception of policy. The same corroborate the fact that the insured had a history of Hypertension since 3 years, Diabetes Mellitus and Cervical Spondylitis as well.

    As per the initial assessment sheet prepared by Paras Hospital, Gurgaon, the insured's blood pressure reading was 150/100 mmHg, which is higher than normal range of limit and same can be corroborated with the fact that the insured is a case of Hypertension before the inception of policy.

    The high blood pressure is the force of blood pushing against the arteries as the heart pumps blood is too high, which causes gradual damage to the arteries, including those to the brain and increases the risk of irregular, often rapid heart rate that commonly causes poor blood flow.

13. Thereafter opposite party Nos.1 and 2 have also reproduced Clause 6.1, reproduction of which is not considered necessary at this stage.

14. It is also pleaded that the policyholder had the opportunity to declare the insured's history of Hypertension, Diabetes and Cervical Spondylitis at the time of filling-up the proposal form, but no such disclosures were made for the reasons best known to the policy holder. The complainants had another opportunity to declare the insured's history of Hypertension, Diabetes and Cervical Spondylitis at the time of filling up the Pre-Medical Examination Form. On the basis of the disclosures made in the Pre-Medical Examination Form, opposite party Nos.1 and 2 conducted a set of medical examination of the insured. No such disclosures were made for the reasons best known to the complainants.

15. After factual position, opposite party Nos.1 and 2 have raised the additional submission that the information given by the proposer about the proposed insured in the proposal form and medical examination form in case of insurance forms the foundation of contract of insurance between the proposer/insured and the insurance company. The insurance works on the principle of utmost good faith. As such, considering the information given by the proposer in the proposal form to be true and correct, does the insurance company takes decision over issuance/non-issuance of any policy. The main spirit and object of insurance is to meet the risk of uncertainty of the insured by the insurer during the term of the policy. The claims are paid by any insurance company out of the common pool of funds belonging to all policyholders of the company, which makes it obligatory upon the insurance company to check the genuineness and admissibility of each claim before, honoring it in the larger interest of all the policyholders. The insurance company cannot do injustice to genuine policyholders by allowing inadmissible claims.

16. On merits, opposite party Nos.1 and 2 have reiterated their stand and controverted all the averments of the complainant. In the end, opposite party Nos.1 and 2 have prayed for dismissal of complaint.

17. In the written version, opposite party No.3 has raised the legal objections that the complaint is not maintainable as opposite party No.3 does not deal in business of insurance and no claim was lodged with it. Opposite party No.3 cannot sanction or reject any insurance claim. There is no deficiency on its part. On merits, it is denied that opposite party No.3 got any blank signatures of the complainants on any documents. All other averments of the complainants are denied. In the end, opposite party No.3 has also prayed for dismissal of complaint.

18. Parties were asked to produce the evidence.

19. In support of their claim, the complainants have tendered in evidence photocopy of declaration, (Ex.C1); photocopies of letters, (Ex.C2 to Ex.C5); photocopy of bills alongwith treatment record, (Ex.C6); photocopy of legal notice, (Ex.C7); postal receipts, (Ex.C8 and Ex.C9) and returned envelop, (Ex.C10)..

20. To rebut the claim of the complainants, opposite party Nos.1 and 2 have tendered into evidence affidavit of Avirraaj Singh dated 4.1.2019, (Ex.OP1/1); photocopy of policy, (Ex.OP1/2); photocopy of terms and conditions, (Ex.OP1/3); photocopy of discharge summary, (Ex.OP1/4); photocopy of denial of pre-authorization, (Ex.OP1/5); photocopy of claim form, (Ex.OP1/6); photocopy of rejection letter, (Ex.OP1/7); photocopy of medical record, (Ex.OP1/8); photocopy of nursing assessment sheet, (Ex.OP1/9); photocopy of initial assessment sheet, (Ex.OP1/10); photocopy of proposal form, (Ex.OP1/11); photocopy of check list, (Ex.OP1/12) and photocopy of opinion, (Ex.OP1/13).

21. Opposite party No.3 has not produced any document.

22. We have heard learned counsel for parties and gone through the file carefully.

23. Learned counsel for complainants after reiterating his stand, has further submitted that admittedly, the complainants were insured with opposite party Nos.1 and 2. Manjit Kaur complainant took treatment from Paras Hospital, Gurgaon for the period from 13.1.2017 to 15.1.2017 and spent Rs.49,341/- for treatment. Opposite party Nos.1 and 2 have repudiated the claim vide letter dated 6.4.2017, (Ex.C5) and (Ex.OP1/7). In this letter, specific reason for rejection of claim is not mentioned, but it is simply mentioned that the claim is rejected for non-disclosure of material facts/pre-existing ailments at the time of proposal. Opposite party Nos.1 and 2 were supposed to specify concealment of ailment to justify rejection of claim. From the written version, it emerges that they are taking plea that the complainant Manjit Kaur is suffering from Hypertension, Diabetes Mellitus and Cervical Spondylitis, but there is no evidence to prove that she was suffering from these diseases and she has ever taken treatment for these diseases. Opposite party Nos.1 and 2 are mainly relying upon statement of Dr.Sunita Gupta, which is made part of Ex.OP1/8. Of-course, it is mentioned 'HTN for 3 years', but name of patient is not mentioned in this report. Similarly, in Ex.OP1/8, it is mentioned that when insured consulted for first time and answer is 3 years back for swelling in legs. This information is obtained by opposite party Nos.1 and 2 from Dr.Sunita Gupta, but name of hospital or even address of doctor is not mentioned in this document. Therefore, alleged statement of Dr.Sunita Gupta has no relevancy.

24. It is further submitted by learned counsel for complainants that opposite party Nos.1 and 2 have also tried to take help of nursing assessment sheet, (Ex.OP1/9). Of-course, in this document, it is mentioned Hypertension, DM and Cervical Spondylitis, but period is not mentioned. Therefore, from this document, it is not to be inferred that the complainant Manjit Kaur is having pre-existing disease. Opposite party Nos.1 and 2 have also pleaded that as per initial assessment sheet, patient was having blood pressure 150/100 mmHg, but this fact also will not prove that hypertension was pre-existing. Therefore, repudiation of claim is not susttainable. It amounts to deficiency in services on the part of opposite parties. The complainants are entitled to reimbursement as well as compensation.

    To support these submissions, learned counsel for complainants have cited following case law:-

    i) Veerpal Nagar Vs. HDFC Standard Life Insurance Company, II 2019 CPJ 59;

    ii) Oriental Insurance Company Limited Vs. Ramesh Kumar, 2018(2) CPJ 253;

    iii) Religare Health Insurance Company Ltd. Vs. Swarn Kanta Jain, 2018(3) CPJ 1;

    iv) Rajinder Singh Vs. New India Assurance Company Limited, 2018(3) CLT 187;

    v) Life Insurance Corporation of India & Ors. Vs. Kunari Devi, 2008(4) CPJ 89;

    vi) National Insurance Co. Ltd. Vs. Shri Rajender Kumar Garg, 2017(4) CPJ 20

    vii) Decision of Hon'ble National Commission rendered in Revision Petition No.1318 of 2014 in First Appeal No.1495 of 2009 dated 1.5.2014 in case Bajaj Allianz Life Insurance Co. Ltd and Others Vs. Raj Kumar.

25. On the other hand, learned counsel for opposite party Nos.1 and 2 has submitted that the contract of insurance is based on good faith. Both parties are under obligation to disclose true facts in the proposal form, copy of proposal form is brought on record, (Ex.OP1/11). Of-course, the complainants have pleaded that their signatures were obtained on blank papers, but they were having no reason to put signatures on blank papers. In this proposal form, they have categorically denied from having any pre-existing decease. As per complainants themselves, the complainant Manjit Kaur was suffering from Palpitation. This Forum can take judicial notice of the fact that hypertension is main cause of Palpitation. The complainants have denied from suffering from hypertension or any other disease. After receipt of claim, matter was got investigated. The complainant Manjit Kaur has admittedly taken treatment from Paras Hospital, Gurgaon. The information was collected from Dr.Sunita Gupta, who has also examined patient Manjit Kaur on 13.1.2017. She has categorically mentioned that the complainant Manjit Kaur was suffering from 'HTN for 3 years'. Her report is Ex.OP1/8. Similarly, nursing assessment sheet, (Ex.OP1/9) reported by Paras Hospital, Gurgaon also finds mentioned that past history is 'Hypertension, DM and Cervical Spondylitis'. Therefore, it is proved on the basis of medical record that patient Manjit Kaur was suffering from Hypertension, DM and Cervical Spondylitis. These diseases were concealed by the complainants at the time of obtaining policy. Opposite party Nos.1 and 2 were justified to repudiate the claim for concealment of material facts.

    To support these submissions learned counsel for opposite party Nos.1 and 2 has cited following case law:-

    (i) 2009 (4) CPJ 8 case titled Satwant Kaur Sandhu Vs. New India Assurance Company Ltd.;

    (ii) 2008 (3) CLT 380 titled P.C. Chacko and another Vs. Chairman, Life Insurance Corporation of India and others;

    (iii) 2010 (3) CPC 222 case titled M/s. Suraj Mal Ram Niwas Oil Mills (P) Ltd., Vs. United India Insurance Co. Ltd.,. and another;

    (iv) 2009 (2) CPC 593 case titled Vikram Greentech (I) Ltd., and Anr., Vs. New India Assurance Co. Ltd.;

    (v) Decision of Hon'ble Apex Court rendered in Civil Appeal No.3944 of 2019, Decided on 15.4.2019 in case Life Insurance Corporation of India Vs. Manish Gupta.

26. Learned counsel for opposite party No.3 has reiterated his stand as taken in the written version and detailed above.

27. We have given careful consideration to these rival submissions and gone through the case law cited by learned counsel for complainants and opposite party Nos.1 and 2.

28. Admitted facts are that the complainants got insurance policy from opposite party Nos.1 and 2 regarding medical claim. The complainant Manjit Kaur remained admitted in Paras Hospital, Gurgaon from 13.1.2017 to 15.1.2017 and she lodged the claim of Rs.49,341/-.

29. Opposite party Nos.1 and 2 have repudiated the claim vide letter dated 6.4.2017, (Ex.C5). As per this letter, they have repudiated the claim on the ground of non-disclosure of material facts/pre-existing ailments at the time of proposal. The material facts or pre-existing diseases allegedly concealed are not specifically mentioned in the impugned letter. From the written version, it is inferred that opposite party Nos.1 and 2 have asserted that the complainants have concealed the earlier diseases of 'Hypertension, DM and Cervical Spondylitis'. Therefore, point for determination is that whether the complainant Manjit Kaur was suffering from these diseases while availing policy and whether opposite party Nos.1 and 2 have been able to prove this fact.

30. In case of Veerpal Nagar (Supra), Hon'ble Delhi State Commission after examination of number of authorities, explained the situation in which pre-existing disease can be established/proved. It was observed that unless and until a person is hospitalization or undergoes operation for particular disease in near proximity of obtaining insurance policy or any disease in which she has never been hospitalization or undergoes operation, is not pre-existing disease.

31. In the light of aforesaid observations, it is to be seen whether opposite party Nos.1 and 2 have been able to establish any pre-existing disease concealed by the complainants or not. In the written version, opposite party Nos.1 and 2 have relied upon following observations to establish pre-existing diseases:-

    “As per the statement given by Dr.Sunita Gupta who initially checked the insured and referred her to Paras Hospital. Gurgaon states that the insured is hypertensive since 3 years. The doctor has also stated the insured first consulted her 3 years back with complaint of swelling in legs, which was due to hypertension only. The insured is hypertensive since 3 years, was not disclosed to opposite party Nos.1 and 2 at the time of inception of policy.

    As per nursing assessment sheet issued by Paras Hospital, Gurgaon, the insured has a past history of Hypertension Diabetes Mellitus and Cervical Spondylitis, which was not disclosed to opposite party Nos.1 and 2 at the time of inception of policy. The same corroborate the fact that the insured had a history of Hypertension since 3 years, Diabetes Mellitus and Cervical Spondylitis as well.

    As per the initial assessment sheet prepared by Paras Hospital, Gurgaon, the insured's blood pressure reading was 150/100 mmHg, which is higher than normal range of limit and same can be corroborated with the fact that the insured is a case of Hypertension before the inception of policy.

    The high blood pressure is the force of blood pushing against the arteries as the heart pumps blood is too high, which causes gradual damage to the arteries, including those to the brain and increases the risk of irregular, often rapid heart rate that commonly causes poor blood flow. ”

32. Opposite party Nos.1 and 2 have not produced on record any statement of Dr.Sunita Gupta. However, one document, (Ex.OP1/8) is brought on record, which is stated to be signed by Dr.Sunita Gupta. The name of patient Manjit Kaur is handwritten and not printed. It is mentioned that Manjit Kaur was suffering from swelling of legs 3 years back and etiology for ailments mentioned for swelling is due to hypertension. In next page also, it is mentioned that 'HTN 3 years', but it is nowhere mentioned that this recorded information given by the patient. The prescription slip of Dr.Sunita Gupta dated 13.1.2017 is also part of record. The name of patient is simply mentioned as Manjit Kaur. No other particular is mentioned. No reference of any past history is mentioned in Ex.OP1/8. Therefore, in these circumstances, it can be inferred that Dr.Sunita Gupta was having no record to mention the past history or other ailments. As such, this document will not prove any pre-existing disease.

33. Opposite party Nos.1 and 2 have also tried to get support from nursing assessment sheet, copy of which is Ex.OP1/9. In the past history recorded in this document, it is simply mentioned 'Hypertension, DM and Cervical Spondylitis', but the period from which patient is suffering from these diseases is not mentioned. The policy was obtained firstly from 21.3.2015 to 20.3.2016. It was to be proved that the complainant Manjit Kaur was suffering from Hypertension etc. prior to 21.3.2015 and was in the knowledge of this fact. Therefore, nursing assessment sheet is also not going to prove version of opposite party Nos.1 and 2.

34. Opposite party Nos.1 and 2 have also tried to get support from initial assessment sheet wherein blood pressure is mentioned as 150/100 mmHg. At the cost of repetition, from this report also, it cannot be presumed that the patient was suffering from HTN even prior to availing policy in question.

35. The conclusion is that opposite party Nos.1 and 2 have failed to prove that the complainant Manjit Kaur was suffering from Hypertension and she was in the knowledge of this disease and she has concealed this fact. As such, repudiation of claim is not sustainable. It amounts to deficiency in services on the part of opposite party Nos.1 and 2.

36. For the reasons recorded above, the complaint is partly accepted with Rs.10,000/- as cost of litigation and compensation against opposite party Nos.1 and 2 and dismissed qua opposite party No.3. Opposite party Nos.1 and 2 are directed to pay the claim amount of Rs.49,341/- alongwith interest on this amount @ 12% per annum from the date of repudiation of claim i.e. 6.4.2017 till realization.

37. The compliance of this order be made within 45 days from the date of receipt of copy of this order.

38. The complaint could not be decided within the statutory period due to heavy pendency of cases.

39. Copy of order be sent to the parties concerned free of cost and file be consigned to the record.

    Announced:-

    13-06-2019

    (M.P Singh Pahwa)

    President

     

     

    ( Mrs.Manisha)

    Member