JUDGEMENT

          Complainant by filing this complaint has submitted that complainant purchased one Mediclaim Insurance Policy with provision for Medical and Hospitalisation Insurance coverage that is hospitalization benefit policy being No.100480048128500000830 with the op after due formalities a certificate of insurance was issued by the op covering risk of Rs. 1,00,000/- for overall capital sum insured Rs.1,00,000/- and said insurance coverage was extended to the family members of the complainant from time to time being completely satisfied about the insured.

          On 05.06.2012 complainant’s daughter met with an accident while taking step sustained injuries and immediately she was rushed to Dr. Partha Chatterjee on 06.06.2012 and after clinical investigation it was oversured by the doctor that the nasal septum of the complainant no.2 i.e. Koel Majumder was deviated due to such injury or as a result of said injury and subsequently she was consulted with the recommended doctor Santanu Banerjee.  After considering all aspects and condition of the complainant no.2, she was advised for Septoplasty.  Accordingly on 07.11.2012  as per advised of the doctor, Koel Majumder was admitted to Woodlands Hospital and on the next day i.e. on 08.11.2012 she underwent Septoplasty under General Anesthesia and ultimately she was discharged on 10.11.2012.

          Thereafter complainant obtained claim form of the op no.1 and submitted the claim to op on 03.12.2012 for settlement of the claim in respect of the treatment cost of the Koel Majumder at Woodlands Hospital.  But on 14.04.2013 op repudiated the claim informing the fact to the complainant on the ground Deviated Nasal Septum followed by congenital diseases above referred claim stands excluded as per clause 4.8 of Standard Medical Policy terms.  But actually the claim of the complainant does not include cases and/or instances of congenital extreme diseases or defects or anomalies and also does not fall with exidents due to nuisance of drugs of alcohol and/or use of intoxicant substances.  It is also out of place to mention that as terms of the said policy as per list of procedures as agreed by referring provider networks of Hospitals Septoplasty is very much included therein and against for repudiation of the claim of the complainant, complainant wrote a letter dated 07.01.2013 asking the op to reconsider the view of the matter taking into all relevant documents into account.  But op kept silent and did not answer for which the demand letter was sent on 03.06.2013 by his Advocate but no result and in the circumstances for in action of the Insurance company for violation of the terms and conditions of the policy and also for negligent and deficient manner of service, complainant has filed this complaint for reimbursement of Rs.73,030/- as hospitalization expenses, medicines, doctors fees which has been incurred by the complainant.

          On the other hand op nos.1 & 2 by filing written statement submitted as per discharge certificate of Woodlands Multispeciality Hospital Ltd. dated 10.11.2012 the patient was suffering from Deviated Nasal Septum (DNS) followed by congenital disease and so the claim is treated as non-admissible and stands repudiated as per Clause No.4.8 of Standard Mediclaim Policy and thereafter op after due application of their mind and considering the Medical Certificate repudiated the claim vide their letter dated 14.01.2013 which was duly acknowledged by the complainant on 15.01.2013 and op submits that Insurance Company had taken decision of the claim after due application of its mind and on good faith and the decision of the repudiation of claim by the op was based on material as produced by the complainant.  So, there is no deficiency in service on the part of the op and fact remains complainant made some false allegations in the complaint about sustaining such injury etc and so the present complaint should be dismissed.

                                                  Decision with reasons

          On overall evaluation of the arguments as advanced by the Ld. Lawyers of both the parties and also considering the ground for repudiation as made by the ops, it is found that ops have tried to convince that the allegation of the complainant is false regarding sustaining injury by Koel Majumder.  But it is the ops’ version that the repudiation was made under Clause-4.8 of the policy.  Now we shall have to consider what the condition of Clause-4.8 is.  So, we are representing the said clause as convalescence general debility ‘Run Down’ condition or rest cure, congenital external disease or defects or anomalies, sterility, infertility sub fertility or assisted conception procedures, venereal disease, intentional self-injury, suicide, all psychiatric and psychosomatic disorder diseases, accidents due to misuse or abuse of drugs/alcohol or use of intoxicating substance and considering the clause 4.8 it is found that any insured is not entitled to any claim if it is found that prior to date effect of the policy the insured has been suffering from any sort of congenital external diseases/defects or anomalies, sterility or for other ground.

          So, apparently after considering Clause-4.8 if any bodily defect is detected as congenital defect in that case invariably at the time of filling application form for purchasing the Mediclaim Policy it was not disclosed in that case invariably for non-disclosure of the material fact regarding the status of the health for existence of any deformity or defect in respect of any fractural affairs of the body and if in respect of that any portion is made after purchasing of the said policy, in that case no doubt insured shall not have to get any such benefit of the Mediclaim Policy.

          In this case practically as per repudiation letter lastly dated 10.12.2012, it is found that claim was stood repudiated as per clause-4.8 of Standard Mediclaim Policy and reasons for repudiation is that as per discharge certificate of Woodlands Multispeciality Hospital dated 10.11.2012 the patient was suffering from DNS followed by congenital disease.  So, the claim is treated as non-admissible and stands repudiated.  But Ld. Lawyer for the complainant submitted that actually Koel Majumder on 05.06.2012 met with an accident while taking steps and sustained injuries and due to said injury nasal septum of Koel Majumder was deviated and for which Dr. S. Banerjee advised for her operation and admission and accordingly on 08.11.2012 complainant no.2 underwent Septoplasty under General Anesthesia and was discharged on 10.11.2012 and in fact it was not for any defect which was in existence prior to purchasing the said policy and it was not congenital disease due to fracture of nasal septum was deviated.

          But op did not consider that fact.  Anyhow we shall have to consider whether the complainant’s version in the complaint regarding sustained injury of Keol Majumder due to fall from the staircase is at all truth and can it be believed.  In this regard we have gone through the discharge summary and from that discharge summary, it is found the above history of the patient Koel Majumder was complained on recurrent of nasal obstruction and that history of Rhinitis and that recurrent nasal obstruction was due to deviated nasal septum and to give her permanent solution of recurrent nasal obstruction due to deviated nasal septum, doctor underwent Septoplasty under General Anesthesia on 08.11.2012.  But nowhere in the discharge certificate, there was no history of sustaining injury for which definition of nasal septum was caused.  Rather it is proved from the said discharge certificate that patient had been suffering recurrent nasal obstruction due to deviated nasal septum which was in existence since birth and in this regard we have gone through the Medical Dictionary and authoritative book of entry wherefrom we have gathered that recurrent nasal obstruction is caused due to deviated nasal septum that means since birth the nasal septum was not in order and it was deviated from its position.  So, considering that fact it is clear that Koel Majumder had been sustained any sort of fracture or any injury due to her claim by the complainant.  But no doubt in the complaint only to get treatment deviated nasal septum was due to fall is explained.  But after consulting medical authoritative book of ENT, it is found that deviate nasal septum is generally a formation since birth and for which the child suffers from recurrent nasal obstruction and in this case from the discharge certificate of Woodlands Multispecialty Hospital, it is clear that Koel Majumder did not sustain any sort of injury due to fall and DNS was not caused of her fall but it was by birth and for which suffering from recurrent nasal obstruction and it was aggravated at the age of 21 years when it was operated and DNS is one of kind of deformity by birth and only by operation it can be cured.

          Fact remains complainant in the complaint has procured a false story about fall of present patient Koel Majumder and sustained injury on her nasal bone that is false and fabricated and discharge certificate issued by Woodlands Multispecialty Hospital supports that complainant’s entire story about sustained injury in the nasal bone is false and fabricated.  Rather it is proved that the patient Koel Majumder had been suffering from recurrent nasal obstruction due to deformity of nasal bone that DNS.  In this regard we want to ventilate the word- Septum that means a partition such as that in between the nostril or the nasal chamber, Deviated means the actual position of the said partition bone was not in proper form since birth and there is gulf on difference in between the DNS and fracture on septum and in the present medical discharge certificate issued by Woodlands Multispecialty Hospital, there is no such past history that she had fallen from staircase and sustained injury and nasal bone was found crack and was dislocated and as per medical treatment DNS means the deformity in the septum since birth.

          So, complainant entire story regarding sustained injury in the nasal septum is completely false and fabricated and only for the purpose for getting the present claim it was procured with higher brain.  But anyhow the discharge summary of Woodlands Multispecialty Hospital has confirmed that Koel Majumder had not sustained any injury and DNS was not due to fall but truth is that she had been suffering from recurrent nasal obstruction due to deformity of nasal bone that is DNS to the left.

          So, it is clear that prior to purchase of the policy, Koel Majumder had been suffering from DNS and that was not disclosed.  But it is the duty of the insured to declare the material fact and matter in respect of her any sort of deformity or defect in respect of the body but that was suppressed.

          Another factor is that the policy was effective from 19.05.2012 to 18.05.2013 whereas the present operation was made in between 07.11.2012 to 10.11.2012,  So, it is clear that as per policy condition Clause-4.8 for any operation in respect of existing deformity in the nasal bone the insured is not entitled to get any benefit of the Mediclaim Policy.  Another factor is that complainant was aware of the fact that Koel Majumder had been suffering from recurrent nasal obstruction due to DNS and only for proper operation of the same at proper stage they are waiting and ultimately the operation was done in respect and that deformity of the nasal bone that is by Septoplasty and she was cured by operation.  But it was not caused for any fall and it was not fracture.  So, invariably the TPA after consulting all the medical documents and the Insurance Company after relying upon the said documents and report of the TPA repudiated the claim on evaluation of the terms 4.8 of Standard Medical Policy.

          So, in this regard we have gathered that the repudiation was made rightly relying upon the discharge certificate issued by the Woodlands Multispecialty Hospital because the present operation was done by Woodlands Multispecialty Hospital on the nasal bone of the patient Koel Majumder in respect of her deformity of nasal bone (DNS) which was since birth.  Nowhere in the said discharge certificate, it is noted that Septoplasty was done for fracture due to fall and history as presented by the patient party was that she was suffering from recurrent nasal obstruction and invariably that was due to DNS and for which Septoplasty was done under General Anesthesia  on 08.11.2012 that means that Koel Majumder had her pre-existing disease and for which she had been suffering many times treated by doctor, but all those documents are not produced and truth is that DNS is one kind of deformity of nasal bone since birth and that is proved from the doctors discharge certificate and no doubt op relied upon the that document and repudiated the claim under Clause-4.8 and also on the ground that complainant did not disclose this fact at the time of purchasing the policy.  Then no doubt complainant committed breach of policy.

          In this regard we have gathered that practically op acted with all sincerity consulted all documents and applied their judicious mind and good faith and thereafter repudiated the claim.  When that is the fact then there is no other alternative but to hold that repudiation as made by the op was justified legal and valid and the repudiation and the decision of repudiation of claim by the op was made on the basis of materials collected and produced by the complainant after enquiries and after applying their judicious mind they did it and fact remains op had no other alternative but to repudiate.  But in view of the fact, complainant’s own discharge certificate supports the fact that complainant cocked up false story in the complaint about causing fracture of nasal bone.  But it is proved a false story and complainant included that story only for getting the claim knowing fully well that if they rely upon discharge certificate whole heartedly in that case claim shall be turned down under Clause 4.8 and when it was repudiated then this false story of accidental fracture of nasal bone due to fall for taking steps is cocked up in his complaint.  No doubt complainant is dishonest insured and at the same time the dishonest insured cannot be a honest consumer.  But it is fact that a consumer must be honest and fair at the time of filing a complaint.  But in the present case by cocking up false story about DNS has tried to get the benefit of the claim.  But truth is that there was no negligence or deficiency on the part of the op and complainant has failed to prove any such deficiency by any means and in view of the above fact and also considering upon the ruling reported in 1997 (1) CPR 22 (NC) and also 1997 (1) CPR 40 (NC) we are convinced to hold that the act of the insurer cannot be challenged or questioned as an act of deficiency in service in this case and practically complainant failed to prove any deficiency in service or negligence on the part of the op when repudiation of the claim of the complainant was duly made on the basis of the material documents filed by the complainant and in view of the above findings we are convinced to hold that the present complaint bears no merit in the eye of law and deficiency and negligence on the part of the op has not been proved and at the same time complainant cocked up a false story about sustaining injuries at her nasal bone for which the operation was done but actually the complaint was done for removal of DNS which was deformity of the patient since her birth and for which she has been suffering recurrent nasal obstruction for long period and has been treated and that is also suppressed in the complaint.

          In the result, the complaint fails.

          Hence, it is

                                                         ORDERED

          That the complaint be and the same is dismissed on contest against the ops but without any cost.