JUSTICE V.K.JAIN (ORAL)

          The complainant/petitioner obtained a health insurance policy for a sum assured of Rs. 2,00,000/- from the respondent for the period from 05.03.2009 to 04.03.2010. During subsistence of the policy he was treated in Escorts Heart Institute from 28.01.2010 to 03.02.2010.  He incurred expenditure of Rs. 4,10,691/- on his treatment. The claim submitted by him for reimbursement in terms of the insurance policy, however, was rejected vide a letter dated 30.01.2010 on the ground that the treatment had been taken for an ailment from which the complainant was suffering at the time of obtaining of the policy and he had not disclosed the same while obtaining the policy.  Aggrieved from the repudiation of the claim the complainant approached the concerned District Forum by way of a consumer complaint.

2.      The complaint was resisted  by the insurance company primarily on the ground on which the claim had been repudiated.

3.      The District Forum allowed the consumer complaint and directed the insurer to pay a sum of Rs. 2,00,000/- to the complainant.   Being aggrieved from the order passed by the District Forum, the insurer approached the concerned State Commission by way of an appeal.  Vide impugned order dated 23.11.2012 the State Commission allowed the appeal and dismissed the consumer complaint.  Being aggrieved the complainant is before this Commission.

4.      The learned counsel for the insurer has drawn my attention to a pre-authorization form which the insurer had received from Escorts Hospital where the complainant was taken for treatment.  Initially, complainant was taken to Batra Hospital and from there he was taken to Escorts Hospital where the treatment was taken.  It is stated in the authorization form purporting to be signed by the complainant that the patient was suffering from diabetes mellitus for 20 years.  The learned counsel for the insurer has also drawn my attention to a report given by the panel doctor of the insurer who had visited Escorts Hospital on 29.01.2010 and who was informed that the patient had history of diabetes mellitus for 20 years.  The above-referred document was not filed before the District Forum and, therefore, could not be proved through evidence.  An application had been filed by the insurer for placing on record the pre-authorization form which the insurer received from Escorts Hospital. Keeping in view the relevance of the document, the insurer is permitted to place on record the said document subject to payment of Rs. 20,000/- as costs to the complainant.  The insurer also needs to be given an opportunity to prove the above-referred documents i.e. pre-authorization form as well as the report prepared by its panel doctor.  The insurance policy is also allowed to be filed.  The impugned orders are set aside and the matter is remitted back to the District Forum to decide the complaint afresh after giving an opportunity to the insurer to prove the additional documents.  The complainant will also be entitled to lead evidence in rebuttal.  The consumer complaint will be decided afresh after considering the additional evidence as well as the evidence already produced by the parties.  Considering the age of the case the District Forum shall decide the complaint afresh within 3 months of the parties appearing before it.  The parties shall appear before the District Forum on 16.09.2020.