Complainant Sudhir Gupta vide the present complaint filed U/S 12 of the Consumer Protection Act, 1986 (hereinafter for short The Act) for issuance of the necessary directions to the titled opposite parties United India Insurance Company Ltd,Gurdaspur and Amritsar to pay Rs.2,64,546/- alongwith 12% interest from the date of letter dated 22.1.2014 till realization alongwith Rs.10,000/- as litigation.

2.       The case of the complainant in brief is that  he took Can Bank Medico Claim Policy in the year 2012 from opposite party no.1 vide policy No.2003004812410000213 valid from 30.04.2013 to 25.04.2014 and the sum insured as per the policy was Rs.5,00,000/-. He suddenly fell ill due to heart problem. He got admission in Medanta Medicity on 20.1.2014 and discharged on 29.01.2014 under the supervision of Dr.Naresh Tarhen. His bye pass surgery was done in the hospital. The disease came to the knowledge after 1.3/4 years after getting the medico policy. He submitted his Medi Claim to the opposite parties, but the opposite parties declined the mediclaim with the remarks that the disease was pre-existing disease. The same is illegal without any justification. The opposite party declined the claim illegally. This is clear cut deficiency in service on the part of the opposite party. Hence this complaint.

3.       Upon notice, the opposite parties insurer appeared through their counsel and filed their written version  taking the preliminary objections that the complaint filed by the complainant against the opposite party is hopelessly premature and the present complaint is bad for mis-joinder and non-joinder of the necessary parties. On merits, it was submitted that the complainant till the date neither lodged his claim with the opposite party, nor gave any information to the opposite parties regarding the alleged claim, hence the question of repudiation of the alleged claim does not arise. The complainant had made the request to the M/s.Paramount Health Services (TPA) Pvt.Ltd. for pre-authorization of his hospitalization, which was denied by the said M/s.Paramount Health Services (TPA) Pvt. Ltd., on the ground that the complainant was suffering with pre-existing disease and its related complications, which is not covered under the terms and conditions of the policy. It was next stated that at the time of making the request for Cashless Hospitalization under medical insurance policy to the third party administrator, the complainant had given the detail of his past history of chronic illness, in which he had admitted that he has been suffering with Diabetes since 8 to 10 years, Heart disease since 4 years and Hypertension since 3 years. Hence, it is crystal clear that the complainant was suffering with pre-existing diseases, which is not covered under the terms and conditions of the policy. Hence, there is no deficiency in service on the part of the insurance company. Other allegations of the complainant have been denied and specifically controverted.  Lastly the complaint has been prayed to be dismissed with costs.

4.       Complainant tendered into evidence his affidavit Ex.CI, along with the other documents exhibited as Ex. C2 to Ex C5 and closed the evidence.

5.        On the other hand, the opposite party tendered into evidence affidavit of Surinder Singh, Divisional Manager U.I.I. Ex.OP1, alongwith the other documents Ex.OP2 and Ex.OP10 and closed the evidence.

6.     We have carefully gone through the pleadings of both the parties; arguments advanced by their respective counsels and have also appreciated the evidence produced on record with the valuable assistance of the learned counsels for the purposes of adjudication of the present complaint.

7.     From the pleadings and evidence on record it is an admitted fact that complainant took Medico Claim Policy from the opposite party vide Policy No.2003004812410000213, valid from 30.4.2013 to 25.4.2014 and as such is a consumer as defined in the provisions of Consumer Protection Act. The case of the complainant is that he suddenly fell ill due to heart problem and was admitted in the Medanta Medicity on 20.1.2014 and was discharged on 29.1.2014, whereas a bye-pass surgery was conducted in the Hospital. The complainant submitted the Mediclaim which was declined by the opposite party.

8.       On the other hand, the counsel for the opposite party has submitted that the complainant never lodged his claim with the opposite party nor even ever gave any information to the opposite party regarding the medi claim and as such the complaint is premature and no cause of action arises in favour of the complainant. We find that it is a fit case which can be disposed off by giving directions to the parties. Hence, we direct the complainant to lodge its claim first before opposite parties with all documents in his possession within 15 days from the receipt of copy of orders. The opposite party is also directed to decide the claim within 30 days from the lodging of claim and submitting of the documents by the complainant. No order as to costs.

9.       Copy of the order be communicated to the parties free of charges. After compliance, file be consigned.                                                                                                                                                         

      (Naveen Puri)

                                                                          President   

Announced:                   (G.B.S.Bhullar)                     (Jagdeep Kaur)

February 12, 2015                        Member                                     Member

*MK*