BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No.28-14

Date of Institution:21-01-2014

Date of Decision:03-03-2015  

S.Harjit Singh (aged 39 years) son of S.Raghbir Singh, resident of 2019, Sarain Bhola Singh, Number 2 Kanta School, Amritsar.

Complainant

Versus

The Star Health and Allied Insurance Company Limited, SCO 25, First Floor, Ranjit Avenue, District Shopping Complex, Amritsar.

Opposite Party

Complaint under section 11 and 12 of the Consumer Protection Act, 1986 as amended upto date.

Present: For the Complainant: Sh.Vikram Puri, Advocate

              For the Opposite Party: Sh.S.S.Salaria, Advocate

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Mr.Anoop Sharma, Member     

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by Sh.Harjit Singh under the provisions of the Consumer Protection Act alleging therein that he obtained medi claim policy under Family Health Optima-New bearing No.P/211111/2014/000939 for a period of one year from 8.7.2013 to 7.7.2014 from Opposite Party against requisite premium of Rs.5017/- covering the risk of himself and his spouse namely Rajinder Kaur to the tune of Rs.2 lacs. Complainant alleges that during the validity period of the insurance policy in question, the complainant fell down from the stairs of his house on 11.7.2013 and he was admitted in Navpreet Hospital on the same day and he remained admitted in Navpreet Hospital from 11.7.2013 to 15.7.2013 and he was discharged from the hospital on 15.7.2013 and Rs.57000/- were incurred on the treatment as well as medicine, tests etc. of the complainant. After discharge of the complainant from the said hospital, the complainant lodged claim with the Opposite Party and requested for reimbursement of medical expenses and the complainant also provided all the relevant documents to the Opposite Party, but the Opposite Party repudiated the claim of the complainant vide letter dated 14.11.2013 on the ground that the complainant suffered injury on 7.7.2013 and policy also commenced on 8.7.2013 at 8 PM and detail of date of incident and injury were concealed.  Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite party to pay the claim amount of Rs.57000/- alongwith interest @ 18% per annum from the date of lodging of claim till payment. Compensation and litigation expenses were also demanded.
2. On notice, opposite party appeared and filed written version in which it was submitted that the complainant has not come to this Forum with clean hands and suppressed the true and material facts from this Forum, as such, the complainant is not entitled to any relief as claimed for. On receipt of the claim intimation regarding medical treatment and hospitalization and subsequently  papers regarding medical treatment from insured, the same were investigated and claim was duly processed and it was found that insured/ patient was treated for fracture of left tibia lower end. It is stated that in order to ascertain the date on which the above  injury was sustained, the Opposite Party entrusted the claim for investigation and in the investigation, it was revealed that the injury was suffered on 7.7.2013 and out patient treatment was taken in the hospital namely Navpreet Hospital, G.T.Road, Pultighar, Amritsar on the same day, whereas the insurance policy was taken on 8.7.2013 after the injury  was suffered and the policy commenced as from 8 PM on 8.7.2013. Thus, it was found that the details of date and time of the incident leading to the above ailment was suppressed and the claim has been made fraudulent for injuries suffered prior to investigation of the policy. Even the doctor of the said hospital has given in writing that advance payment of Rs.5000/- was deposited in the said hospital on 8.7.2013 whereas the patient was admitted in the hospital on 7.7.2013 and this shows that the policy has been obtained by concealment of facts and by misrepresentation and playing fraud with a view to get wrongful gain. It is further submitted that as per discharge card, the admission date is shown as 11.7.2013 and discharge date as 15.7.2013 and from the medical record searched by the investigating team, when the patient was admitted in the hospital on 7.7.2013 and advance payment was deposited in the hospital on 8.7.2013, whereas the policy was obtained at 8 PM on 8.7.2013. So, the claim of the complainant being not genuine is not payable and has rightly been repudiated vide repudiation letter dated 14.11.2013. While denying and controverting other allegations, dismissal of complaint was prayed.
3. Complainant tendered into evidence his affidavit Ex.C-1 alongwith documents Ex.C2 to Ex.C17 and closed the evidence on behalf of the complainant.
4. Opposite Party tendered into evidence affidavit of Sh.Rajnish Kohli, Vice President Ex.OP1 alongwith documents Ex.OP2 to OP18  and closed the evidence on behalf of the Opposite Party.
5. We have carefully gone through the pleadings of the parties; arguments advanced by ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for both the parties.
6. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that  the complainant obtained medi claim policy under Family Health Optima-New bearing No.P/211111/2014/000939 from Opposite Party for the period from 8.7.2013 to 7.7.2014  Ex.C2 on payment of premium of Rs.5017/- covering risk of complainant himself and his spouse namely Rajinder Kaur with sum assured of Rs.2 lacs. Complainant alleges that during the validity period of the insurance policy in question, he fell down from the stairs of his house on 11.7.2013 and was admitted in Navpreet Hospital, G.T.Road, Pultighar, Amritsar where  he remained admitted there  from 11.7.2013 to 15.7.2013  as per discharge card Ex.C4. He incurred about Rs.57000/- on his treatment as well as medicine, tests etc. as per bills Ex.C5 to Ex.C12. After discharge from the said hospital, the complainant lodged claim with the Opposite Party, but the Opposite Party vide letter dated 14.11.2013 Ex.C13/ Ex.C14 repudiating the claim of the complainant on the ground  that the complainant suffered injury on 7.7.2013 and he was taken to the aforesaid hospital i.e. Navpreet Hospital, G.T.Road, Pultighar, Amritsar on the same day, but the complainant obtained the policy in question on 8.7.2013. Ld.counsel for the complainant submitted that as per certified issued by Navpreet Hospital, G.T.Road, Pultighar, Amritsar Ex.C17, the complainant was admitted in that hospital on 11.7.2013 and was discharged on 15.7.2013 and remained under treatment for fracture of left tibia lower end. The Opposite Party has wrongly repudiated the claim of the complainant. Ld.counsel for the  complainant submitted that all this amounts to deficiency of service on the part of the opposite party.
7. Whereas the case of the opposite party is that on receipt of the claim intimation from the complainant regarding medical treatment, the Opposite Party got investigated the claim and it was found that insured/ patient was treated for fracture of left tibia lower end. The investigator submitted his  report Ex.OP15. The investigator also got letter from Amrik Singh of Navpreet Hospital, G.T.Road, Pultighar, Amritsar dated 10.3.2014 Ex.OP6 and the investigator concluded that the complainant suffered injury on 7.7.2013 and he was admitted in Navpreet Hospital, G.T.Road, Pultighar, Amritsar on 7.7.2013 and he deposited the hospital charges with Navpreet Hospital, G.T.Road, Pultighar, Amritsar on 8.7.2013 amounting to Rs.5000/- whereas the policy in question was taken by the complainant with commencement date as 8.7.2013 at 8 PM which proves that the aforesaid information regarding the date and time of the incident leading to above ailment was suppressed by the complainant and he has obtained the policy by misrepresentation to get wrongful gain from the Opposite Party. Not only this, the complainant has produced on record two discharge cards from Navpreet Hospital, G.T.Road, Pultighar, Amritsar i.e. one Ex.OP10 which shows that the complainant remained admitted from 11.7.2013 (8 PM) till 15.7.2013 (5 PM)  and another discharge card is Ex.OP17 which shows that the complainant remained admitted in Navpreet Hospital, G.T.Road, Pultighar, Amritsar on 11.7.2013 to 13.7.2013 whereas the computerized record of Navpreet Hospital, G.T.Road, Pultighar, Amritsar shows that the  complainant was admitted in Navpreet Hospital, G.T.Road, Pultighar, Amritsar on 7.7.2013. Resultantly, the Opposite Party has repudiated the claim of the complainant vide letter dated 14.11.2013 Ex.OP12.   Ld.counsel for the opposite party submitted that there is no deficiency of service on the part of the opposite party.
8. From the entire above discussion, we have come to the conclusion that  the complainant obtained medi claim policy under Family Health Optima-New bearing No.P/211111/2014/000939 from Opposite Party for the period from 8.7.2013 to 7.7.2014  Ex.C2 which fully proves that the complainant obtained  this policy on 8.7.2013 with commencement date 8.7.2013 from 8 PM onwards. The complainant alleges that he fell down from the stairs of his house on 11.7.2013 and was admitted in Navpreet Hospital, G.T.Road, Pultighar, Amritsar where  he remained admitted there  from 11.7.2013 to 15.7.2013  where he spent about Rs.57000/- on his treatment as well as medicine, tests etc. as per bills Ex.C5 to Ex.C12.  The claim was lodged with Opposite Party. Resultantly, the Opposite Party appointed investigator who looked into the matter and submitted his report Ex.C15. The Opposite Party also obtained requisite information from Navpreet Hospital, G.T.Road, Pultighar, Amritsar. Resultantly, Amrik Singh of Navpreet Hospital, G.T.Road, Pultighar, Amritsar gave his report in which he submitted that as per the computer record, complainant Harjit Singh was admitted in their hospital due to treatment for fracture of left tibia lower end on 7.7.2013 and a sum of Rs.5000/- was deposited as hospital advance by the complainant/ his attendant on 8.7.2013 and this entry has been physically checked  by the  official of the Opposite Party Sh.A.K.Sharma who investigated the matter from his computer on 10.3.2014. This report Ex.OP6 has duly been proved by Amrik Singh Accountant of Navpreet Hospital, G.T.Road, Pultighar, Amritsar vide his affidavit Ex.OP2, in which this witness has categorically deposed that Harjit Singh (complainant) was admitted in their hospital as patient on 7.7.2013 and he deposited Rs.5000/- as advance in the hospital on 8.7.2013 as per record of their hospital. The complainant was given opportunity to cross examine this witness. In the cross examination, no question or suggestion has been put forward to this witness that the complainant was not admitted in Navpreet Hospital, G.T.Road, Pultighar, Amritsar on 7.7.2013, rather he was admitted on 11.7.2013. So, this part of the statement of this witness that patient Harjit Singh was admitted  in their hospital on 7.7.2013 remained unrebutted or unchallenged. The case of the complainant also becomes doubtful because he himself has produced two discharge cards from Navpreet Hospital, G.T.Road, Pultighar, Amritsar i.e.  one Ex.OP10 which shows that the complainant remained admitted from 11.7.2013 (8 PM) till 15.7.2013 (5 PM)  and another discharge card is Ex.OP17 which shows that the complainant remained admitted in Navpreet Hospital, G.T.Road, Pultighar, Amritsar from 11.7.2013 to 13.7.2013. So, from the  entire above discussion, it stands fully proved that the complainant suffered injury i.e. fracture of left tibia lower end  due to fall from the stairs of his house on 7.7.2013 and he was admitted in Navpreet Hospital, G.T.Road, Pultighar, Amritsar on 7.7.2013 whereas he obtained  the present policy from the Opposite Party on 8.7.2013 by misrepresentation of facts. It has been held by Hon’ble National Commission in case Smt.Shakuntala Vs. Life Insurance Corporation of India in 2014(2)CLT page 261  that where insured had undergone surgery for removal of his gall bladder prior to the submission of proposal form and the aforesaid fact was concealed from the insurance company, it is clear case of concealment of material information by the insured. Similar are the facts of the present case. Consequently, we hold that the Opposite Party was justified in repudiating the claim of the complainant vide letter dated 14.11.2013 Ex.OP12.
9. Resultantly the complaint is without merit and the same is hereby dismissed with no order as to costs. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Dated: 03-03-2015.                                                (Bhupinder Singh)                                                                                                  President

                                                                       (Kulwant Kaur Bajwa)

                                        Member

                                (Anoop Sharma)

hrg                                                                            Member