Judgement is delivered in open Commission.

BY -    SRI ASISH DEB, PRESIDENT

Brief facts of the complainant case is that the complainant is a permanent resident under the jurisdiction of this Commission and his address is described in the cause title. The Complainant is a simple, innocent and peace-loving citizen. The complainant has purchased a Mediclaim Policy vide No. 150305501910000653 from the National Insurance Company Ltd., Tamluk Branch for the period from 11.09.2019 to 10.09.2020 which was issued by National Insurance co. Ltd, Tamluk Branch for an insured amount of Rs. 1,50,000/-. The Complainant has got slipped and fell down in the bathroom at home on 02.11.2019 with complaints of pain in lower back and both legs; pain is greater in left leg compared to right leg, pain increases on standing for longer duration, he was unable to walk properly. After attending by local doctors the complainant was admitted at Fortis International Hospital Limited, Rajajinagar, Bangalore, on 13.11.2019 and was discharged on 16.11.2019. During the period from 13.11.2019 to 16.11.2019 the Complainant (patient) was posted for surgery department of Orthopedic in Fortis International Hospital Limited, Rajajinagar, Bangalore. The total expenditure incurred in the hospital is Rs. 1,05,183/-. The complainant submitted an application for Rs. 1,05,183/- as Mediclaim against the policy along with all investigation report, Medical bills, discharge certificate of Fortis International Hospital Ltd. On 09.12.2019 at the office of National insurance Co. Ltd. Tamluk Branch, but the O.P. denied the Mediclaim to the Complainant vide their letter dtd. 18.02.2020. Thereafter, the complainant went to the office of the O.P. and requested them to release the Mediclaim in favour of the Complainant but they did not care to settle the claim. The Complainant submits that the O.P. is not diligent rather negligent to render the service to the complainant as such the complainant claiming benefit of the policy. The Complainant has not any source of income at this stage, he urgently requires benefit of claim from the O.P. The Complainant faces loss/damages which has been caused by the O.P.; and unfair acts and deficiency in service by the O.P. resulted a loss of Rs. 1,05,183/- plus interest from the date of filing of this complaint plus litigation cost. The Complainant is residing in the district of Purba Medinipur which is within the jurisdiction of this Forum of District of Purba Meidnipur at Tamluk. The cause of action arose on and from 18.02.2020 when the O.P. refused to make the payment for benefit of claim in favour of the complainant. The Complainant prays for direction of payment of Rs. 1,05,183/- plus interest from the date of filing of this complaint plus litigation cost from the O.P.

Upon service of notice the op contested the case by filing written version. The sum and summerisation of the written version are that the case is not maintainable in its present form and in law.  The op submitted that save and except the statements which are the matters on record all other statements as made in different Paras of the complaint is false, baseless and very much denied and the Complainant is put to the strict proof of all such statements as made in those Paras. All the statements as made in Para 3 of the complaint that the complainant has slipped or fell in the bathroom at home on 02.11.2019 or with complaint of pain in lower back or both legs or pain greater in left leg compared to right leg or pain or increases on standing for longer duration or unable to walk properly are false, baseless,  manufactured for the purpose of this case. . Medical bills or Discharge certificate of Fortis International Hospital Ltd. are manufactured for the purpose of this case .The complainant has got no cause of action for initiating this case. The prayers as made in the instant complaint in Para 14 are false, baseless, imaginary, indefinite and illegal. The complainant is not entitled to get any relief on this Complaint from the Ld. Commission. The instant complaint being filed beyond the scope of Insurance Policy, the same is liable to be rejected. The Complainant can not get any benefit for the breach of any specific terms and conditions including the exclusion clauses of the Insurance Policy as issued by this O.P. This O.P. Insurance Co. most humbly submits that the Complainant obtained the National Mediclaim Policy with effect from 11.09.2019 to 10.09.2020 by suppressing his pre-existing disease of spinal problems. On 10.12.2019 this O.P. Insurance Co. received a signed claim form from the Complainant for the reimbursement of his stated treatment for spinal cord for an amount of Rs. 1,05,183.00 stating to have been treated at Fortis International Hospital Ltd. At Bangalore as was admitted on 13.11.2019 and discharged on 15.11.2019. All the documents submitted relating to the claim was sent to the Medi Assist India Insurance TPA Pvt. Ltd. For due processing of the claim as per the terms of Policy and they have thoroughly checked the claim along with all the medical papers submitted, where from and particularly from the discharge Summary it is found that the stated patient-complainant was treated and underwent “STABILIZATION OF L5 AND S1 WITH PEDICLE SCREWS AND POSTERIOR DECOMPOSITION OF CANALAND L5 S1 DISECTOMY”. The treatment as was undergone for his pre-existing disease and to get undue insurance benefit the complainant has made out various pre- planned false story in his complaint in connivance with the Hospital Authority at Bangalore as would also be evident from the submitted prescription of Dr. R. N. Dey of Tamluk dt. 02.11.2019 and also the X-Ray Report dt. 02.11.2019 of Sree Aurobindo Diagnostic & Analytical Centre, Tamluk as well as the MRI Report of ‘Spectrum’, Diagnostic & Health Care, Bangalore dt. 11.11.2019. After thorough scrutiny of all the submitted medical papers, the TPA i.e. Medi Assist India Insurance TPA Pvt. Ltd. And they vide their letter dt. 27.01.2020 advised this O.P. Insurance Co. to repudiate the claim being the same is for pre-existing disease being excluded in respect of the availed Insurance Policy within the meaning of the terms, conditions and exclusions clauses and this O.P. Accordingly, the claim of the Complainant has been repudiated and was informed to him vide registered post 19.02.2020. But the complainant has suppressed about that letter though he received the same in due course of postal services. As such the complainant is not at all entitled to get the benefits over this Mediclaim Policy as raised. There is no deficiency of service and illegality on the part of this Opp. Party .The Complainant has initiated this case before this Ld. Commission without any cogent ground and on some baseless and illegal claims which are not at all permitted in law as per terms of contract of Insurance Policy. It is further submitted that the instant case has been initiated by the Complainant for getting some wrongful gain over the Policy which was availed by him for the first time and only for a year and not a continuous policy. The instant Consumer case being otherwise bad the same is liable to be dismissed with exemplary costs to this Opp. Party.

Points for determination are:

1. Is the case maintainable in its present form and in law?          

2.  Is the Complainant entitled to the relief(s) as sought for?

Decision with reasons

Both the points, being inter related to each other, are taken up together for discussion  for sake of brevity and  convenience.

We have carefully perused the affidavit of the complainant and evidence produced by Complainant and op, and documents as annexures. On total appraisal of the materials on records along with bundle of facts it appears that the complainant is a Consumer. The case is maintainable in its present form and in law.

Now , on scanning the evidence of complainant it is evident he stated that he has purchased a Mediclaim Policy vide No. 150305501910000653 from the National Insurance Company Ltd., Tamluk Branch for the period from 11.09.2019 to 10.09.2020 which was issued by National Insurance co. Ltd, Tamluk Branch for an insured amount of Rs. 1,50,000/-. The Complainant has got slipped and fell down in the bathroom at home on 02.11.2019 with complaints of pain in lower back and both legs.

There is no dispute that the complainant has purchased a Mediclaim Policy vide No. 150305501910000653 from the National Insurance Company Ltd., Tamluk Branch for the period from 11.09.2019 to 10.09.2020 which was issued by National Insurance co. Ltd, Tamluk Branch for an insured amount of Rs. 1,50,000/-. It is the prima facie burden on the complainant that he should prove the fact that he has got slipped and fell down in the bathroom at home on 02.11.2019. With a view to proving the said fact the complainant has relied upon a prescription ( Exbt-1 ) dated 02.11.2019 issued by Dr R N Dey ; the said prescription does not reflect any history of  slipped and fell down in the bathroom at home on 02.11.2019. Another prescription issued on 11.11.2019 by Dr . Kumarswamy (Exbt-1h) shows that the patient visited the doctor with a complain of fall from bike yesterday. The complainant placed the claim before the Manager of the OP on 04.12.2019 wherein he did mention the facts of accidental injury sustained from slip and falling in the bathroom the reason best known to him. The documents filed by the complainant falsify the versions of the complaint. On the contrary those prescriptions and other documents establish the contentions of the op averred in the written version to the effect that the treatment as was undergone for his pre-existing disease as would be evident from the submitted prescription of Dr. R. N. Dey of Tamluk dt. 02.11.2019 and also the X-Ray Report dt. 02.11.2019 of Sree Aurobindo Diagnostic & Analytical Centre, Tamluk as well as the MRI Report of ‘Spectrum’, Diagnostic & Health Care, Bangalore dt. 11.11.2019. After thorough scrutiny of all the submitted medical papers, the TPA i.e. Medi Assist India Insurance TPA Pvt. Ltd. and they vide their letter dt. 27.01.2020 advised this O.P. Insurance Co. to repudiate the claim being the same is for pre-existing disease being excluded in respect of the availed Insurance Policy within the meaning of the terms, conditions and exclusions clauses . Accordingly, the claim of the Complainant has been repudiated and it was informed to him vide registered post on 19.02.2020. The complainant is not entitled to get the claim as he is debarred by the terms and conditions of the insurance policy. The reason for repudiation, as mentioned in the letter dated 18.02.2020 as exclusion under clause no-4.1 all pre- existing diseases...48 months, was valid. The treatment undergone by the complainant fell in the mischief of exclusion under clause no-4.1 .Now, coming to the reply given by the complainant, it appears that complainant has failed to demolish the above versions of the op. The complainant has failed to bring home the elements of deficiency of service against the op . There is no deficiency of service and illegality on the part of this Opp. Party.  Resultantly, complainant is not entitled to get any relief in this case.

Both the points are disposed of accordingly.

Thus, the case fails.

Hence, it is

O R D E R E D

That CC/18 of 2021 be and the same is dismissed on contest.

        Let a copy of the judgment be supplied to each of the parties free of cost.