BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.

                                                          Consumer Complaint no. 200 of 2012                                                             

                                                        Date of Institution         :    28.9.2012

                                                          Date of Decision   :  29.9.2016.

Sunil Kumar Garg son of Shri Krishan Lal M/s. Hans Raj Madan Lal Cloth Merchants, Mandi Dabwali, District Sirsa.

            ….Complainant.                     

                   Versus

1. United India Insurance Co. Ltd., Mandi Dabwali, Distt. Sirsa through its Branch Manager.

2. Vipul Medicorp TPA Pvt. Ltd., 515 Udyog Vihar, Phase-V, Gurgaon.

                                                                             ..…Opposite parties.

            Complaint under Section 12 of the Consumer Protection Act,1986.

Before:        SHRI S.B.LOHIA…………………PRESIDENT

                 SHRI RANBIR SINGH PANGHAL ……….……MEMBER.

Present:       Sh.A.K. Gupta,  Advocate for the complainant.

     Sh. Ravinder Monga, Advocate for opposite party no.1.

Opposite party no.2 exparte

ORDER

                   Case of complainant, in brief, is that he purchased a Health Policy no.111901/48/09/97/00000118 for the period from 29.9.2009 to 28.9.2010 from opposite parties for himself and his family members. The complainant was insured against a sum of Rs.1,50,000/- and the policy was renewed from 29.9.2010 to 28.9.2011. The complainant developed a problem of incisional hernia having swelling a midline of abdomen and doctors of Medanta Hospital, Gurgaon advised to undergo surgery for which he was admitted there on 26.9.2010. The complainant produced medi-claim card issued by op no.2 to the hospital but hospital authority told that they are not going to accept the cashless card due to negative attitude of the company in settling the claim and the complainant was required to deposit the amount in cash. The complainant decided to get the treatment by making payment of the bills of hospital in cash and then to lodge the claim. He gave required intimation regarding his treatment well in advance on 24.9.2010. He underwent surgery and after the treatment, the complainant lodged the claim to the op. However, the op started harassing the complainant and started unnecessary correspondence and stated that intimation should be given within 24 hours after admission and claim should have been submitted within 15 days after discharge despite the fact that hospital had duly informed the op regarding his admission. The op has kept a total silence over the matter and has not settled the claim inspite of his repeated requests. Earlier complaint filed by him was withdrawn due to some technical defect. The complainant is entitled to a sum of Rs.2,53,597/- spent by him on his treatment besides compensation of Rs.50,000/- on account of harassment and Rs.11,000/- as litigation expenses from ops. Hence, this complaint.  

2.                Upon notice, opposite party No.1 appeared and contested the complaint  by filing written statement pleading therein that at the time of purchasing the individual health insurance policy, the complainant was well aware about his previous ailment but he had deliberately not disclosed the same in the proposal form. After receiving the medical record from the hospital, the same was scrutinized through op no.2 and found swelling in midline of abdomen at the site of previous incisional scar for last two and half years with no pain or tenderness. History of spleenectomy three years back for blunt trauma abdomen. The complainant while submitting the proposal form suppressed the relevant fact regarding his previous ailment, which is mandatory as per the terms of insurance policy. Hence, op cannot be held liable for any deliberate violation of the terms and conditions of the insurance policy by the insured.

3.                Opposite party no.2 did not appear despite service through registered cover and acknowledgment was received and was proceeded against exparte.

4.                By way of evidence, the complainant has tendered his affidavit Ex.P1 (Ex.C1) and documents Ex.C2 to C11. On the other hand, op no.1 tendered affidavit Ex.R1 and documents Ex.R2 to R6.

5.                We have heard learned counsel for the parties and have gone through the case file carefully.

6.                There is no dispute between the parties regarding purchasing of the Health policy by the complainant from the ops which was purchased for the period from 29.9.2009 to 28.9.2010 and was subsequently renewed from 29.9.2010 to 28.9.2011. The claim of the complainant has not been settled by the ops on the ground that complainant has not disclosed about his previous ailment to the ops in the proposal form. According to the opposite parties, a specific question was put to the complainant in proposal form Ex.R4 that whether he suffered from or are suffering from any illness prior to the inception of the policy and the complainant replied in negative i.e. “No”, however, from the discharge summary of Medanta Hospital Ex.R5, it is evident that patient Sunil Kumar i.e. complainant was admitted for elective surgery for incisional hernia, having swelling in midline of abdomen at the site of previous incisional scar for last two and half years with no pain or tenderness. According to the ops, it is also mentioned that history of spleenectomy 3 years back for blunt trauma abdomen and complainant concealed this fact from the ops. However, in our view the stand of the opposite parties is not correct. As the above said disease was got removed by the complainant very earlier i.e. more than two years prior before taking the policy in question, so the complainant correctly answered that he is not suffering from any illness and it cannot be said that he concealed the factum of his previous ailment from the ops. The opposite parties have illegally and wrongly not settled the genuine claim of the complainant on the ground of concealment.

7.                 Keeping in view the abovesaid discussion, we reached at the conclusion that the complainant is entitled for the hospital expenses incurred by him for his treatment as per medical bills of the hospital and medicines purchased by him during the period of hospitalization.

8.                 Resultantly, this complaint is hereby allowed, with a direction to insurance company i.e. to the opposite parties, to pay hospitalization expenses/ settle the claim of the complainant within a period of two months from today. A copy of this order be supplied to the parties free of costs. File be consigned to record room after due compliance

Announced in open Forum.                                     President,

Dated: 29.9.2016.                                                District Consumer Disputes

                                                                           Redressal Forum, Sirsa.

                                      Member.