BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

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Ramneek Sood, s/o Sh.R.K.Sood, r/o Flat No.7, GH-38, MDC, Sector 5, Panchkula.

…..Complainant

                           V E R S U S

1] The United Insurance Co. Ltd, SCO 836, 1^st Floor, NAC, Manimajra, Chandigarh through its Branch Manager.

2] Med Saves Health Care Ltd., SCO 121-123 Sector 34, Chandigarh (TPA of United Insurance Co. Ltd.) through its Branch Head

                                  ……Opposite Parties

CORAM:  SH.JAGROOP SINGH MAHAL PRESIDENT

              SH.RAJINDER SINGH GILL    MEMBER

Argued by: Sh. Subash Chander, Adv. for complainant.

Sh. Nitin Gupta, Adv. proxy for Sh.R.C. Gupta Adv. for OP No.1.

OP No. 2 exparte.

PER SHRI JAGROOP SINGH MAHAL, PRESIDENT

             Brief facts of the case are that the complainant took a med claim insurance policy from OP-1 covering all his family members, that the complainant alongwith his wife Ms. Anu Sood went to Chennai to see his sister-in-law, where on 14.02.2008 his wife felt some irritation in her eyes and they visited Sankara Nethralaya, 18 College Road, Chennai for normal consultation. The Doctor recommended certain tests at the hospital and it was found that she had a problem of Retino Blastoma   in her right eye.  She was admitted in the hospital on 15.02.2008 and was discharged on 18.02.2008 with the instructions to report back to the hospital for review on 6.03.2008. The complainant alongwith his wife again visited the said hospital on 6.03.2008, she was again admitted in the hospital on that date for treatment and was discharged on 11.03.2008 with instructions to review the treatment on 27.03.2008.  The complainant again visited the said hospital on 27.03.2008 and his wife was again admitted in the hospital for treatment and was discharged on 31.03.2008.  The complainant had to visit the said hospital alongwith his wife for consultation and spent a total of Rs.1,06,017.19 paisa on her treatment.  The bills were submitted to OP-1, who requested for certificate from the treating Doctor/Hospital which was provided to the OP.  However, the OP rejected the claim on the ground that it was a pre-existing disease. The complainant therefore prayed for a direction to the OPs to pay the amount of Rs.1,06,017.19 paisa alongwith interest @12% p.a. from 5.02.2009 with Rs.20,000/- as compensation for mental agony, pain harassment and deficiency in service and Rs.5,000/- as costs of litigation.

2.             United Insurance Company Limited-OP No.1 opposed the compliant on the ground that there was no deficiency or unfair trade practice on their part.  The complainant was alleged to have concealed material facts to grab easy money from the OP.  It was contended that elaborate evidence and cross-examination of witnesses was required and therefore the complaint be relegated to the Civil Court for proper adjudication.  On merits it was admitted that med claim insurance policy was obtained by the complainant for himself and his family members which was valid from 4.02.2008 to 3.02.2009.  It was however denied if irritation in the eyes was felt for the first time on 14.02.2008.  Their contention is that it is case of perpetuation of the fraud by the complainant and his wife on the OP.  According to them the Retino Blastoma is the most common eye cancer which occurs in the childhood and therefore the wife of the complainant was suffering from the disease and knew about it since before the date the med claim insurance policy was taken.  It was alleged that the complainant has withheld the other records wherein the history of the disease and diagnosis were mentioned by the Doctors concerned. The manner in which the complainant and his wife went to Chennai for treatment instead of getting her treated from P.G.I. at Chandigarh was said to be sufficient to speak about the ingenuineness of the complaint.  They prayed for calling the entire record of Sankara Nethralaya Hospital, Chennai which would show the history of disease and also its duration to reach at just conclusion.  The OP-1 prayed for dismissal of the complaint.

3.             OP-2 was served but did not appear for it and was proceeded against exparte.

4.             Both the parties produced affidavit in support of their contentions.

5.             We have heard the arguments of the Learned Counsel for the Parties and have perused the record.

6.             The primary question involved in this case is whether the wife of the complainant was suffering from Retino Blastoma and knew about it since before the date the med claim insurance policy was taken by the complainant or not.  The OP-1 has produced the affidavit of Dr. Roli Aggarwal who is the Regional Manager of Med Save Health Care OP No.2.  According to him the investigation conducted by his Branch Manager at Chennai revealed that Ms. Anu Sood visited Sankara Nethralaya, Chennai for the first time on 19.12.2007 and was diagnosed as OD Adult on set Retino Blastoma and had undergone the doses of Chemotherapy from 26.12.2007 to 29.12.2007.  According to Dr. Roli Aggarwal the patient was well aware of the disease before the inception of the policy on 4.02.2008.  After coming from Chennai the present policy was taken by the complainant effective from 4.02.2008 and thereafter the complainant again went to Chennai on 14.02.2008 for the treatment of his wife.  The Learned Counsel for the OP-1 has referred to the email Annexure OP1/H in which also this information was conveyed.  The OP also referred to the affidavit of Anil Grover, Deputy Manger, in which also it was mentioned that the complainant was getting treatment from Sankara Nethralaya, Chennai on 19.12.2007 onwards even before the commencement of the policy of insurance which started from 4.02.2008 to 3.02.2009.

7.             Since the complainant did not mention in his complaint regarding his earlier visit to Sankara Nethralaya, Chennai on 19.12.2007 and thereafter, nor did he file the affidavit of the patient Ms. Anu Sood who was treated in the said hospital, it was ordered vide order dated 26.02.2010 that the information be obtained from Sankara Nethralaya, Chennai on the following points:-

1.  Whether Smt. Anu Sood, wife of Ramneek Sood, (who was subsequently admitted in the hospital on 15.02.2008 for Retino Blastoma-right eye S/P Chemotherapy and was discharged on 18.02.2008) had visited the hospital near about 19.12.2007?

2.  Whether on that day Fundus test was conducted on her and she was diagnosed as OD Adult on set Retino Blastoma?

3.  Whether she had undergone the doses of Chemotherapy from 26.12.2007 to 29.12.2007 or near about that?

4.  Whether she again got herself admitted in the said hospital on 15.02.2008 under MRD No. 1643607?

       As per order dated 12.03.2010 the complainant was also directed to file his affidavit giving reply to the above questions.

8.      In his affidavit the complainant admitted in reply to question No.1 that he alongwith his family members had visited the [said] hospital in a normal routine/checkup because of their stay at Chennai for some domestic function near about 19.12.2007. However his reply to question no. 2 and 3 was that he does not have knowledge about the test of fundus conducted on his wife and does not have the knowledge about the nature of treatment being given to his wife during the period 26.12.2007 or near about that. It was deposed by him that he came to know from the treating Doctor when he visited the hospital on 15.02.2008 after the various tests as advised by the Doctor and (?) which was diagnosed to have a Retino Blastoma for the first time in the right eye during the visit on 15.02.2008.  He however deposed that in order to avoid the controversy, he does not want to pursue the present complaint.

9.             The affidavit filed by the complainant leaves much to be said about this episode.  It is admitted by him that he alongwith his wife had visited the hospital on 19.12.2007. It shows there was problem in the eyes because only then they had to visit the hospital. He however did not admit this fact if fundus test was conducted on his wife and chemotherapy was given to her from 26.12.2007 to 29.12.2007.  We cannot believe the complainant about his ignorance on this material aspect relating to a serious disease of his wife.  One thing is certain that the complainant has not denied if fundus test was conducted on his wife and if she was diagnosed as OD Adult on set Retino Blastoma. It was also not denied by the complainant that she had undergone the doses of chemotherapy from 26.12.2007 to 29.12.2007.  It speaks volumes about the pre-existing nature of the disease and the efforts made by the complainant in concealing this fact.

10.                When the complainant found that the reply would come from Sankara Nethralaya Hospital, Chennai and falsehood upon which he has based his complaint would be exposed, he opted to withdraw this complaint.  Infact he appears to be having no other option to avoid prosecution for giving false evidence and filing of false complaint before this Forum with twisted facts.  In our opinion it is a fit case in which the complainant should be prosecuted for concealing evidence, giving false affidavit and filing a false complaint to cause wrongful loss to OP-1 and wrongful gain to himself by claiming the amount of compensation to which otherwise he is not entitled.  The facts which now emerge are that the complainant alongwith his wife Ms. Anu Sood visited the said hospital on 19.12.2007 for the treatment of Retino Blastoma, that fundus test was conducted and doses of chemotherapy were given to her from 26.12.2007 to 29.12.2007.  However, the complete treatment was to cost more than Rs.1,00,000/-, the complainant therefore came back leaving treatment midway and purchased the med claim insurance policy from OP-1 which was effective from 4.02.2008. Equipped with the med claim insurance policy, he again visited the said hospital alongwith his wife on 15.02.2008 and got her admitted in the hospital where she was treated and a bill of Rs.1,06,017.19 paisa was raised.  The complainant submitted the said bill to the OP-1 but OP-1 rejected the claim on the ground that the complainant knew about the disease before the policy was taken by him. However the complainant was not satisfied and may be thinking that his misdeeds would not come to light as the hospital is far away from Chandigarh, he therefore filed the present complaint in which he did not mention if he had visited the said hospital on 19.12.2007 where his wife was examined, he did not mention as to what treatment was given to his wife,  he did not mention for what period she remained under treatment in the said hospital before they came back to Chandigarh to purchase the present policy.  It was a systematic plan under which the complainant was working.  However when the reality came to light and it is proved that the policy was obtained by the complainant after he had come to know of the disease, he has now opted to withdraw the complaint.

11.           In view of the offer made by the complainant, we are of the opinion that no further evidence should be obtained.  We have heard the arguments of the Learned Counsel for the parties.  The Learned Counsel for the complainant does not want to say anything in support of his contentions and has requested that the complaint be dismissed as withdrawn. However, in view of the averments mentioned above, it is clear that it is a false and frivolous complaint having been filed by the complainant due to his greed to earn money to which he is not otherwise entitled.  The facts were concealed by the complainant in a manner to cause wrongful loss to OP-1 and to dodge this Forum. Such like litigants who file false and frivolous complaints require to be dealt with stern hands. However, the costs of Rs.10,000/- provided under Section 26 of the Consumer Protection Act 1986 is far too less to dissuade such like dishonest persons from filing false complaints thereby harassing their opponents.

12.           In view of the above discussion, we are of the opinion that there is no merit in this complaint and the same is accordingly dismissed.  The complainant is directed to pay Rs.10,000/- to OP-1 as costs as provided under Section  26 of the Consumer Protection Act.

              Certified copies of this order be sent to the parties free of charge.  The file be consigned.