DISTRICT CONSUMER DISPUTES REDRESSAL FORUM II
Udyog Sadan C 22 & 23 Qutub Institutional Area
(Behind Qutub Hotel) New Delhi 110016.
Case No. 500/2007
Sh. Ram Rattan Jain S/o J.P. Jain
R/o BQ 90 Shalimar Bagh
Delhi 110032 ….Complainant
Versus
The Manager/Concerned Officer
United India Insurance Co. Ltd.
Branch Office: 124 A Katwaria Sarai
(Opp. Indian Statistical Institute)
Behind Bus Stop New Delhi 110016 …Opposite Party
Date of Institution : 13.04.07 Date of Order : 29.02.16
Coram:
Sh. N.K. Goel President
Ms. Naina Bakshi Member
O R D E R
The case of the complainant in short is that after asking him to undergo ECG test on 1.9.06 and urine test on 20.8.06 the OP issued mediclaim policy bearing No. 040602/48/06/20/00000294 from 12.9.2006 to 11.9.2007 to him. The complainant suddenly fell ill and was admitted in the Sunder Lal Jain Charitable Hospital Ashok Vihar Phase III Delhi 52 on 17.10.2006. He underwent few tests to know the reason of sudden illness (Chest pain) and after examining the report doctors told him that this was an emergency case of ACS THROMBOSIS WITH STENOSIS TO LAD PTCA + STENT TO MID LAD and the complainant took the said treatment and paid Rs. 1 97 000/ to the hospital because since that time the OP had not given him the insurance policy. Para 11 of the complaint reads as under
That the Complainant also filled up the Mediclaim Insurance Claim form in the Hospital which was sent to the doctors panel in Indraprastha Apollo Hospital (Address: Sarita Vihar Mathura Road New Delhi – 110044 Ph. No. 011 51678916) for opinion on the issue that Whether this was a previous disease/ailment or not . The Complainant also filled up in the above mentioned form that it was not a previous disease/ailment and no claim has been made ever till date.
The claim of the complainant was rejected by the OP on the basis of previous disease/ailment on 10.11.06 though the complainant was not suffering from any previous disease/ailment. Complainant sent a legal notice dated 19.2.07 to the OP but to of no effect. According to the complainant he has suffered physical and mental agony on account of the deficiency in service and unfair trade practice on the part of the OP. Accordingly the complainant has filed the present complaint for issuing directions to the OP to pay to him Rs. 3 Lacs along with 18% p.a. interest towards hospital bill mental pain tension and agony and Rs. 25 000/ towards legal expenses.
In the written statement the OP has inter alia stated that the complainant was already suffering from the said disease before taking the mediclaim policy in question but he suppressed this fact from the OP while taking the mediclaim policy in question. Para 11 of the complaint has been replied as follows vide Para 10:
That the contents of para no. 11 of the said complaint are very important and relevant to the facts which the complainant have to prove or have to filed before this learned forum for their perusal. What are the findings of doctors of Indraprastha Apollo Hospital Sarita Vihar Mathura Road New Delhi 110044 yet not furnished before the expert penal of CRM Department of Family Health Plan Ltd. or before the hon ble forum. The disease for which the complainant went for treatment after taking the said Mediclaim policy has to be decided by the penal of expert doctors whether it was pre existing or post existing. Complainant is not a doctor he just purchased the said Mediclaim Policy while hiding the facts that he has no previous disease/ailment hence his filling of the said form having no meaning in this connection and do not deserve any compensation.
It is stated that the claim of the complainant was rejected/repudiated on the basis of the opinion dated 10.11.06 of expert panel of CRM Department of Family Health Plan Ltd. Receipt of the legal notice has not been denied. Denying any deficiency in service/unfair trade practice on the part of the OP prayer is made for dismissal of the complaint.
Complainant has filed a rejoinder.
Complainant has filed his own affidavit in evidence. On the other hand affidavits of Sh. Ajay Kumar Jain Branch Manager and of Dr. Sunil Gupta Sr. Medical Officer Family Health Plan Ltd. have been filed on behalf of the OP.
Written arguments have been filed on behalf of the parties.
Despite giving various opportunities no oral arguments have been advanced on behalf of the parties.
We have gone through the file and the copies of the judgments filed on record very carefully and proceed to decide the complaint.
Admittedly before issuing mediclaim policy to the complainant the OP had required the complainant to undergo the two medical tests i.e. ECG and Urine test. It is a matter of common knowledge that ECG test is required for ascertaining whether the heart of the person is working properly. However at the same time ECG test is not a final test. If ECG is normal the things are OK. However in the ECG report show some negative points then further tests are required to be carried out to rule out or to find out the possibility of the heart ailment. In the present case the complainant has filed the copies of the Cardiac Catheterization & Coronary Angiography Report dated 17.10.06 conducted on him by the Sunder Lal Jain Charitable Hospital which concludes that Single Vessel disease (90% stenosis in the mid portion with thrombus) was found and recommendation was made PTCA/Stent to LAD (Mark A). The complainant has filed only one page of discharge summary bearing No. 1036 (Mark B) which provides the Hospital Course as follows:
Patient presented with ACS CAG shows LAD 90% with Thrombus in mid segment PTCA + stent to LAD done. Patient stablised with NTG drip/T.Clopitab/T.Fcosprin/T.Cardio plus/T.Dilzen/T.Tonact & discharge in satisfactory condition.
Our experience shows that the discharge summary generally contains a brief history of the ailment. The discharge summary also contains the fact whether it was an old existing disease or was a new disease. As stated hereinabove in Para 11 of the complaint the complainant has relied on some report obtained by him from Indraprastha Apollo Hospital. Vide order dated 11.11.08 our predecessors had directed the complainant to file the said opinion on the file. However the subsequent order sheet records that the opinion was not filed by the complainant as directed by the last order sheet. Thus the complainant has withheld a very material medical paper from the OP as well as from this Forum for the reasons best known to him. Had this report/opinion been filed on the record this Forum would have perhaps come to a definite conclusion whether it was a case of pre existing disease or the disease had occurred all of a sudden which possibilities could not be ruled out. Therefore the adverse inference is drawn against the complainant. OPs witness Dr. Sunil Gupta has stated that this type of ailment occurs after long standing dyslipedemia and other factor.
There is absolutely no evidence on the record to even show that it was not a pre existing disease.
Therefore in view of the above discussion we are constrained to hold that the complainant has failed to prove it to be a case of medical deficiency or unfair trade practice on the part of the OP. Accordingly we dismiss the complaint with no order as to costs.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
Announced on 29.2.2016
(NAINA BAKSHI) (N.K. GOEL) MEMBER PRESIDENT
Case No. 500/07
29.02.2016
Present – None.
Vide our separate order of even date pronounced the complaint is dismissed. Let the file be consigned to record room
(NAINA BAKSHI) (N. K. GOEL) MEMBER PRESIDENT
