1.                     The brief history of the case of the complainant is that the complainant had obtained a health insurance policy No.18889424 on 12.4.2011 from the Ops with plan name “Reliance Life Care For You Plan” for premium paying term 3 years and the policy continued for 3 years with regular premium valid up to 12.4.2014 which covers reasonable and customary medical expenses incurred towards hospitalization during policy term with pre and post hospitalization benefits.  It is submitted that after expiry of policy term, as per persuasion of the Ops, the complainant again obtained for the said policy and after submission of all documents, the Ops issued Policy No.51733419 with DOC 13.4.2014 for a policy term of 12 years and premium paying term 3 years on yearly mode.  Mrs. Sunita Sahukar categorically made the complainant belief that as the complainant continued the policy for 4 consecutive years, he will get more benefit in respect of health care from the Company.  It is further submitted that the complainant suffered illness and consulted Dr. Mohit Bhandari of M/s. Mohak Hi-tech Speciality Hospital, Indore who diagnosed the complainant for MORBID OBESITY DM- II and intimated the fact to the OP.1 who advised to collect necessary papers after treatment from the said hospital.  The complainant admitted in the hospital on 05.06.2014 and got operated for Laparoscopic Gastric Bypass on 06.06.2014 vides Regn. No.300884 and Admission No.301733 and on the hospital bed the complainant contacted OP.1 who in turn wishing for good health of the complainant reminded to collect required papers from the hospital for reimbursement purpose.  The complainant discharged from the hospital on 12.6.2014 incurring an expenditure of Rs.1, 71,172/- towards treatment and approached OP.1 at Jeypore who issued claim form and also advised to deposit Rs.13, 000/- with the insurance Co. at the 1^st stage of submitting documents which amount is refundable at the time of 3^rd stage of submitting documents.  The complainant submits that he deposited Rs.13, 000/- along with necessary papers with the Company through OP.1 at the 1^st stage, some documents in 2^nd & 3^rd stage but after a long wait and in spite of assurance, the Ops repudiated the claim on 14.5.2015 without refunding Rs.13, 000/- at the time of 3^rd stage of submission of documents.  Thus alleging deficiency in service on the part of the Ops, he filed this case praying the Forum to direct the Ops to pay the claim amount of Rs.1, 71,172/- with interest @ 18% p.a. from 12.6.2014 and to pay Rs.2.00 lacs towards compensation and costs to the complainant.

2.                     The Ops 1 & 2 filed counter in joint denying the allegations of the complainant but admitted about the “Reliance Care For You Advantage Plan” vide Policy No.51733419 dt.13.4.2014 taken by the complainant from them.  It is contended that the complainant was admitted in the hospital on 05.6.2014 and was discharged on 12.6.2014 and the reason for hospitalization was to be Obesity and the Ops have received claim Vide Membership No.T1205151394 for a claim amount of Rs.1, 71,172/- through Medicare TPA Services (I) Pvt. Ltd(OP.3).  It is further submitted that vide their letter dt.14.5.2015 the Ops denied the claim with reason that the operation for Laparoscopic Gastric Bypass is excluded from the scope of the policy issued by the Company and the disease process is pre existing and hence the claim is not payable.  With these and other contentions, denying any deficiency in service on their part, the Ops prayed to dismiss the case of the complainant.  The OP No.3 in spite of valid notice did not prefer to participate in this proceeding in any manner.

3.                     Parties have filed certain documents along with affidavits in support of their cases.  Heard from the parties through their respective A/Rs and perused the materials available on record.  Both the Ops also filed written arguments.

4.                     In this case it is an admitted fact that the complainant has taken “Reliance Care For You Advantage Plan from the Ops vide Policy No.18889424 on 12.4.2011 which is valid till 12.4.2014.  After expiry of above policy term the complainant has taken same plan again for another term of 12 years vide Policy No.51733419 w.e.f. 13.4.2014 and the premium paying term for 3 years.  The case of the complainant is that he suffered illness and preferred M/s. Mohak Hi-tech Speciality Hospital, Indore for his treatment after consulting the physician there.  The complainant has intimated the fact of his illness to OP.1 who advised to go ahead with the treatment but the Ops later on repudiated the claim of the complainant on the ground that the disease for which the treatment given was pre existing and the treatment of Obesity and its complication are excluded from the scope of the policy.

5.                     In the above circumstances, the following issues emerge importance for just decision of this case.  (1)  Whether the disease for which the complainant has received treatment was pre existing, (2) whether the disease Obesity and its complications are excluded from the scope of the policy,  (3) whether the Ops have committed any deficiency in service and (4) if so, as to what relief?

6.                     While deciding the 1^st issue it was ascertained that the policy taken by the complainant is a health plan specifically to cover the medical expenses if any incurred by the policy holder during subsistence of the policy.  The complainant has taken policy for the 1^st time vides No.18889424 for the period 12.4.2011 to 12.4.2014.  For all the 3 years the complainant has not taken a single pie from the Ops towards his treatment.  According to the complainant, the OP.1 as well as their agent persuaded the complainant for a new policy of same plan with some extra feature.  The complainant opted for the 2^nd policy and the Ops issued Policy No.51733419 with DOC 13.4.2014.  The then OP.1 (Mr. Ram Prasad Sahukar) and the agent (Mrs. Sunita Sahukar) were properly intimated about the disease before going for the treatment.  Now the Ops are grumbling about non intimation of fact of treatment.  The OP.1 and the agent both reside in this locality and the complainant has conveniently intimated the fact to them.  Hence the contention of the Ops that the complainant has not intimated about his proposal for treatment is wrong.  Rather it was the duty of OP.1 to communicate the said fact to other Ops for their knowledge and action.  Further the complainant states that the OP.1 and the agent have advised the complainant to collect papers and bills from the hospital for reimbursement.  It is a fact that cash less treatment is available for tagged hospital and for non tag hospital, the bills are to be reimbursed by the Ops.  When the complainant has successfully cleared the 3 years term without any treatment and has taken the same policy for the 2^nd term, question of pre existing of disease in our opinion does not arise.  The complainant was at liberty to go for treatment of any disease after one year of 1^st policy as per policy terms but in this case no such occasion arose.  When the complainant took the plan and policy for 2^nd term, he has suffered illness and the treatment became necessary during 4^th year of the policy for which he consulted physician.  No such expert evidence is adduced by the Ops proving that the disease process is pre existing.  Without adducing any expert evidence the Ops cannot say that the disease for which the complainant received treatment was pre exist. Reliance can be placed to a decision of Hon’ble National Commission reported in CPR 2009(1) 208 where it has been held that “Life insurance policies, failure to prove suppression of facts, repudiation of claim not justified”.  Insurance Co. cannot take advantage of its act of omission and commission as it is under obligation to ensure before issuing medi claim policy whether a person is fit to be insured or not.  If the insured person had been even otherwise living normal and healthy life and attending to his duties and daily chores like any other person, he cannot be held for concealment of any disease. From the above facts and circumstances, the repudiation of claim on the ground that the disease was pre existing is not acceptable by us.  Accordingly, this issue goes in favour of the complainant.

7.                     While deciding the 2^nd issue it is seen that the Ops have taken another ground for repudiation that the disease Obesity is not covered under the policy.  We have carefully gone through the policy terms at Clause-6, known as exclusion clause.  The term Obesity is nowhere found in the exclusion clause.  No such written term and condition is present showing that the Obesity is not covered under the policy.  It is seen from the hospital documents that the complainant was given treatment for Morbid Obesity and got operated for Laparoscopic Gastric Bypass.  This particular medical term is not available in the exclusion clause.  Hence we are unable to hold the contention of Ops good in this line.  Therefore, this issue also goes in favour of the complainant.

8.                     The OP.1 is the Branch Manager of Reliance Life Insurance Co. having branch at Jeypore.  He is aware about the treatment of the complainant and even in the hospital bed the complainant has contacted the OP.1.  The OP.1 as per his promise has forwarded the claim application of the complainant and documents in 3 stages.  At the 1^st stage of submitting documents the OP.1 has received Rs.13, 000/- from the complainant assuring that during 3^rd stage of submitting documents, the amount so deposited shall be refunded by the Company.  Now the Ops denied receipt of Rs.13, 000/- from the complainant.  No affidavit is filed by the OP.1 (Sri Ram Prasad Sahukar) in support of the contention of the Ops that he has not received any money from the complainant.  It is seen that the complainant has furnished all his documents stage wise and after a long gap of one year the Ops have repudiated the claim with unsustainable pleas.  Therefore, we come to the conclusion that the repudiation is illegal and were made without application of mind.  By not reimbursing the legitimate claim of the complainant, the Ops have committed deficiency in service on their part.  Further, non settlement of claim for one year and subsequent repudiation at belated stage amounts to deficiency in service.

9.                     As per record of the Ops, the complainant has submitted the bills worth Rs.1, 71,172/- and he is certainly entitled to get his legitimate claim from the Ops with due interest.  Further he is also entitled to get refund of Rs.13, 000/- taken by OP.1 during submission of 1^st stage documents.  Due to non settlement of legitimate claim by Ops, the complainant must have suffered some mental agony and has come up with this case incurring some expenditure and hence he is certainly entitled for some compensation and costs of this litigation.  Considering the sufferings of the complainant, we feel a sum of Rs.10, 000 /- towards compensation and costs will meet the ends of justice.

10.                   Hence ordered that the complaint petition is allowed in part and the Ops 1 & 2 being jointly and severally liable are directed to pay Rs.1, 71,172/- towards settlement of claim with interest @ 12% p.a. from the date of repudiation i.e. 14.5.2015 and to pay Rs.10, 000/- towards compensation and costs to the complainant within 30 days from the date of communication of this order.

(to dict.)