Delhi

East Delhi

CC/455/2013

SONU BHOLU - Complainant(s)

Versus

UNITED INDIA INS. - Opp.Party(s)

01 May 2017

ORDER

          DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, EAST, Govt of NCT of Delhi

              CONVENIENT SHOPPING CENTRE, 1^st FLOOR, SAINI ENCLAVE, DELHI 110092  

 

                                                                                                   Consumer complaint no.        455/2013

                                                                                                   Date of Institution               10/06/2013

                                                                                                   Order reserved on               01/05/2017        

                                                                                                   Date of Order                        03/05/2017                                                                                     

 

In matter of

Mr Sonu Bhola, adult   

R/o- A- 89, St No. 8, Jagat puri

Krishna Nagar, Delhi 110051..………………….……………...…………….Complainant

                             

                                      Vs

 

1-M/s Managing Director

United India Insurance Co. Ltd. 

24, Whites House, Chennai 600014

 

2-M/s Manager, United India Insurance Co. Ltd. 

1^st Floor, Govind Mension, Behind Plaza Cinema,

CP, New Delhi 110001

 

3-The Development Officer,

United India Insurance Co. Ltd. 

1^st Floor, Govind Mension, Behind Plaza Cinema,

CP, New Delhi 110001

 

4-The Manager, Vipul Medcorp

505, Udhyog Vihar, Phase V,

Gurgaon, Pin 122016, Haryana……………………..……………..….…………..Opponents

 

Quorum   Sh Sukhdev  Singh        President

                   Dr P N Tiwari                 Member

                   Mrs Harpreet Kaur      Member                                                                                             

 

Order by Dr P N Tiwari  Member  

Brief Facts of the case                                                                                                 

Complainant was a member of Handicap International India group which was insured with OP2 from 2008 under Group Mediclaim Health policy no. 2008/04170148080500000458.His parents as Sh Jaggan Nath aged 60 years and mother Smt Sumitra Devi aged 56 years were entered from 18/03/2010 under Group mediclaim policy no. 2009/041701/48/09/05/00008443 having its tenure from 01/01/2010 to 31/12/2010 vide endorsement no. 3417048090583000220 for sum assured 1.5 Lacs. After getting herself medically examined, she was found having high blood sugar and was noted by the OP2 as annexed Ex. CW1/1.

Complainant’s mother was admitted at Shri Ram Singh Hospital & Heart Institute, Delhi for sudden breathlessness, profuse sweating, restlessness and epigastric pain on 30/05/2012 and during treatment, she expired on 02/06/2012. The cause of death was Hyper-osmolar Non Kitotic Coma. All preventive measures were taken as placing temporary pacemaker and intubation. Complainant stated that his mother was a known diabetic since 15-16 years. The discharge summary was marked as Ex CW1/2.  

The hospital bill for Rs 71,745/-was paid by the complainant vide bill no. 319 dated 02/06/2012 as marked CW1/3. Complainant submitted claim form with treating doctor’s certificate to OP4 for re imbursement on 20/06/2012 as CW1/4 and 5. Later, complainant received repudiation of his claim under exclusion clause 4.1 as Pre existing of Diabetes and its complications on 08/03/2013. It was stated in repudiation letter that claimant/insured was having diabetes since 15-16 years and her name was entered in the said mediclaim policy from 18/03/2010.

Complainant filed this complaint alleging deficiency of services of OPs and claiming refund of his treatment cost/hospital bill with harassment and mental agony.  

OP after receiving notice submitted their written statement denying allegations of deficiency of OPs. It was submitted that OP1 and OP3 were not a necessary parties, hence replying OP was submitting their version for OP2 and 4. Complainant did not disclose material facts about her treatment of Diabetes before endorsement in policy in 2010 while submitting proposal form as cardiac arrest was a known cause of ailment which was a pre existing ailment. So, claim was repudiated as per their terms and conditions of the policy. Hence, this complaint may be dismissed on non disclosure of material facts by the complainant/ insured at the time of getting endorsed in the said group mediclaim policy.  

Complainant filed only his rejoinder to written statement, but did not file evidence on affidavit and also OPs did not file their evidences on affidavit like policy terms and conditions, policy proposal form, related material or higher courts citations for their defence.

 

Even after receiving notices, except OP’s counsel, complainant did not attend his case on number of dates of proceedings. On the date of arguments, complainant did not put his appearance despite being received the notices, so file was perused and order was reserved.

 

We have come to the conclusion that complainant was not serious in defending his case with proper care and interest and wasted Forum’s time also.

It was seen that complainant had stated in his complaint only that at the time of endorsement of his parents name in group mediclaim policy, his mother was found to have high blood sugar and was informed to OPs also, but there was no evidence on record to prove the fact of high blood sugar of his mother. OP 2 also did not submit any evidence on record to support the version of complainant.  

 

It is medically established fact that cardiac arrest is the main cause of death in long standing uncontrolled diabetes. Complainant could not prove his case by any concrete evidence or by any related medical literature in his defense and deficiency in services of OP2 & 4.

 

Hence, this complaint is dismissed for want of proper documents/evidences for reaching to a concrete conclusion of the case.    

Copy of this order be sent to the parties as per Act and file be consigned to Record Room.

 

(Dr) P N Tiwari  Member                                                                         Mrs  Harpreet Kaur  Member                                                                                                                         

                                      

                                                  Shri  Sukhdev Singh  President