DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                                Complaint No.  508

                                                Instituted on:    23.08.2016

                                                Decided on:       25.01.2017

Dr. Sudarshan Jindal son of Shri Madan Lal, resident of Jain Street, Banasar Bagh Road, Patiala Gate, Sangrur.

                                                        …Complainant

                                Versus

1.             The United India Insurance Co. Ltd. through its Divisional Manager, Division Office, Railway Road, Sangrur 148 001.

2.             Medsave Healthcare (TPA) Ltd. through its Area Manager, SCO 66, Second Floor, Sector 40/C, Chandigarh 160036.

                                                                ..Opposite parties

For the complainant  :       Shri Kali Ram Garg, Adv.

For OPs                    :       Shri Gagandeep Singh Sibia, Adv.

Quorum:   Sukhpal Singh Gill, President

                Sarita Garg, Member

                Vinod Kumar Gulati, Member

Order by : Sukhpal Singh Gill, President.

1.             Dr. Sudarshan Jindal, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant had been obtaining the services of the Ops regularly for getting various policies including the one medi claim policy since 17.1.2012.  Further case of the complainant is that the complainant obtained a family medicare policy 2014 bearing number 1117022914P for the period from 16.1.2015 to 15.1.2016 from Sunam Branch of OP number 1.  Further case of the complainant is that unfortunately, the complainant in the month of December 2015 felt pain in his chest and consulted a local doctor at Sangrur, as such he referred the complainant to a Super Speciality Hospital like Medanta Hosptial Gurgaon for better management.   As such the complainant visited Medanta Hospital, Gurgon on 18.12.2015 and after examination the doctor treated the ailment and prescribed some medicines, where he remained admitted in that hospital on 6.1.2016 to 9.1.2016 and during the admission, the stunt was inserted.  The policy in question was cashless policy.  Further case of the complainant is that the wife of the complainant before admitting the complainant for his treatment from the above said hospital, informed OP number 1 to arrange the expenses for the treatment, but the OP number 1 refused to entertain the requst of the complainant.  As the treatment of the complainant was urgent, the wife and other relatives of the complainant arranged for the payment to be made to the hospital at their own.    Thereafter the complainant lodged a medical claim with the OP number 1 against the above said policy for reimbursement of the claim of Rs.2,83,131/-, but the OP number 1 repudiated the claim of the complainant vide letter dated 17.2.2016 on the ground that the claim has been lodged before the expiry of four years from the commencement of the policy as per condition number 4.1.  of the policy, as such, the repudiation of the claim is said to be wrong and false.  Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the OPs be directed to pay to the complainant an amount of Rs.2,83,131/- along with interest @ 18% per annum from 9.1.2016 till realisation and further claimed compensation and litigation expenses.

2.             In reply filed by the OPs, preliminary objections are taken up on the grounds that the complainant has dragged the OPs into unwanted litigation, that the complainant has got no locus standi and cause of action to file the present complaint, that the complainant has not come to the Forum with clean hands and has suppressed the material facts.  On merits,  it is admitted that the complainant obtained the medicare policy in question from the OP.  It is further admitted that the wife of the complainant informed the Op number 1 for getting the treatment from Medanta Hospital, Gurgaon, but the Ops have rightly denied for the cashless treatment on the ground that “the liability of the insurance under this policy is not determinable at present from the details provided to us regarding the story of the insurance and disease. Cashless denied under clause 4.1 (pre existing disease are not payable). Hence, cashless facility cannot be extended in this case.”  An email in this  regard was also sent to Medanta Hospital, Gurgaon on 7.1.2016. However, it is admitted that the complainant submitted the documents, but the claim has been rightly repudiated as per the clause 4.1 of the insurance policy.  As such, any deficiency in service on the part of the Ops has been denied.

3.             The learned counsel for the complainant has produced Ex.C-1 copy of medi claim policy 2007, Ex.C-2 copy of family medicare policy, Ex.C-3 affidavit, Ex.C-4 copy of family medicare policy 2014, Ex.C-5 copy of repudiation letter, Ex.C-6 and Ex.C-7 are the copies of bills and Ex.C-8 is the copy of policy and closed evidence. On the other hand, the learned counsel for the Ops has produced Ex.OP-1 copy of insurance policy, Ex.OP-2 and Ex.OP-3 copies of letters, Ex.OP-4 copy of report dated 7.1.2016 of Medanta Hospital, Ex.OP-5 copy of discharge summary, Ex.OP-6 copy of claim process sheet, Ex.OP-7 copy of repudiation letter, Ex.OP-8 copy of report of Medanta Hospital, Ex.OP-9 copy of insurance policy, Ex.OP-10 copy of proposal form and closed evidence.

 
4              We have carefully perused the complaint, written version of the opposite parties, evidence of the parties and heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits dismissal, for these reasons.

5.             The learned counsel for the complainant has contended vehemently that the complainant is getting the mediclaim insurance policy for the last four years and, as such the complainant got insurance policy bearing number 1117022814P 108657088 for the period from 16.1.2015 to 15.1.2016 from Sunam branch of the OP number 1 and during the subsistence of the insurance policy, the complainant in the month of December, 2015 felt pain in his chest and consulted a local doctor, who referred the complainant to Medanta Hospital Gurgaon for better treatment where stunt was inserted in the body of the complainant and remained under treatment there from 6.1.2016 to 9.1.2016 and spent an amount of Rs.2,83,131/- on his treatment.  But, the grievance of the complainant is that the OPs repudiated the claim of the complainant on the ground that the claim has been lodged by the complainant before the expiry of four years from the commencement of the policy  and as per condition number 4.1 of the policy no claim is payable.  As such, the learned counsel for the complainant has contended vehemently that the claim has been wrongly repudiated by the Ops and has prayed that the repudiation letter be set aside and claim be allowed.  On the other hand, the stand of the OPs is that the complaint should be dismissed with special costs as the complainant has not come to the Forum with clean hands and has suppressed material facts.  It is further contended vehemently that the complainant was having the pre existing disease and was taking treatment for CD & PTCA since the year 2010 and this fact was concealed by the complainant at the time of taking the insurance policy in question.  It is further stated that as per claim document it is found that patient was AK/C/O DM/HTN since 8 years and PTCA done in 2010.  The policy inception date is 16.1.2014 and as per policy condition it was found that the ailment is pre existing and claim has rightly been rejected under clause 4.1, which provides that any pre existing condition(s) as defined in the policy, until 48 months of continuous coverage of such insured person have elapsed, since inception of his/her first policy with the company.  As such, the learned counsel for the OPs has contended that the claim has rightly been rejected by the OPs.

6.             Further the learned counsel for the OPs has drawn our attention towards the document Ex.OP-4 issued by Medanta Hospital, wherein it is clearly mentioned in the column “Previous Interventions: Prior Angiography Double Vessel Disease with patent stent in LAD (07-01-2016). Post PTCA (2010),  meaning thereby the complainant was having pre existing disease and was treated in the said hospital in the year 2010.  We have also perused the copy of discharge summary of the complainant Ex.OP-5, wherein in the column “Diagnosis & Co-morbidities: Coronary Artery Disease, Double Vessel Disease, POST PTCA (S) PROXIMAL LAD (Sept.2010) Hypertension, Type II Diabetes mellitus, BPH”.  Further in the discharge summary Ex.OP-5 in the column “Medical History & Presenting complaints: Dr. Sudarshan Jindal 64 years old is hypertensive, male, known case of Post PTCA (S) proximal LAD, BHP presently asymptomatic, came here for regular check up. He was evaluated for the same and found to have stress thallium positive. He was admitted here for further evaluation and management.   As such, all this shows that the complainant was visiting regularly in the Medanta Hospital, Gurgaon and was taking treatment since the long period and even PTCA was done in 2010 on the complainant in Medanta Hospital, Gurgaon.  It is worth mentioning here that the complainant has suppressed this material fact at the time of getting the insurance policy and even at the time of filing the present complaint.  As such, we are of the considered opinion that the person who does not come to the Forum with clean hands is not entitled to get any claim.   As such, the claim has rightly been repudiated by the OPs under clause 4.1, which provides that any pre existing condition(s) as defined in the policy, until 48 months of continuous coverage of such insured person have elapsed, since inception of his/her first policy with the company.  Admittedly, in the present case the policy of the complainant is not 48 months old nor the complainant has produced any such evidence on record. Even the complainant has not produced on record the insurance policies showing that he has been getting the insurance policies from the Ops since 2012 as mentioned in the complaint. As such, we are of the considered opinion that the claim has rightly been repudiated by the OPs.  The learned counsel for the Ops has cited Satwant Kaur Sandhu versus New India Assurance Co. Ltd. 2009(3) CPC 6 (Supreme Court), wherein the complainant took an insurance policy by concealing the fact that he was suffering from diabetic nephropathy/chronic renal failure and died after seven months of taking the policy, the Hon’ble Supreme Court held that there is no deficiency in service on the part of the Ops in repudiating the claim and repudiation was held to be justified.  Further it has been held by the Hon’ble Court that a mediclaim policy is a non-life insurance policy meant to assure the policy holder in respect of certain expenses pertaining to injury, accidents or hospitalisations. It is a contract of insurance policy falling in the category of contract uberrimae fidei. The same view has also been taken by the Hon’ble National Commission in Subinoy Majumdar versus Life Insurance Corporation of India, Agartala Branch II and others 2016(2) CPR 712.  As such, we are of the considered opinion that the claim of the complainant has rightly been repudiated by the OPs.

7.             In view of our above discussion, we find no merit in the complaint and the same is accordingly dismissed. However, the parties are left to bear their own costs. A copy of this order be issued to the parties free of cost. File be consigned to records.

                Pronounced.

                January 25, 2017.

                                                        (Sukhpal Singh Gill)

                                                           President

                                                                (Sarita Garg)

                                                                    Member

                                                        (Vinod Kumar Gulati)

                                                                   Member