JUDGEMENT

          Complainant by filing this complaint has submitted that complainant is a holder of Mediclaim Policy bearing Policy No.030200/48/10/20/0000/5003 under the op no.1 as consumer under the op.

          In the month of January-2012 the complainant was diagnosed of Arthritis in both knees and was advised for total knee replacement operation after examination by Medical Officer and was referred to be admitted at Apollo Hospital, Ahmedabad, (Gujrat).  Thereafter the left knee replacement operation was conducted on 20.02.2012 by Dr. K.C. Mehta who conducted the said replacement of left knee and similarly on 24.02.2012 right knee was operated and he was released.  Complainant duly lodged its claim under the said Mediclaim Policy with the Paramount Health Services (TPA) Pvt. Ltd. and paid the total knee operation charges as cashless basis.

          Subsequently the complainant again lodged his claim for right knee operation charges to the said TPA to the extent of Rs.2,74,033/- for the said operation which had been conducted at the Apollo Hospitals Ltd. but op released only Rs.1,69,763/- out of the total charges of Rs.2,74,033/-.  TPA also requested that the balance of the claim shall be paid by the op no.2 under Super Top Up policy of the op no.1 but in spite of repeated request and representation all the ops failed to settle the claim as lodged.

          Fact remains that the documents, papers as required under the law for settling claim which is submitted by op no.3 shall be settled by op no.2 as per Super Top Up policy and thereafter complainant sent notice to the op no.1 by his Advocate but op did not respond.  But only to harass the complainant in such a manner against the claim of the complainant shall be settled by the op.  Subsequently op no.2 vide his letter dated 12.06.2012 sought further documents in originals which were already submitted with the claims with the op no.2.  in the circumstances for the negligent and deficient manner of service and unfair trade practice complainant has prayed for released of the balance amount of the Mediclaim Policy i.e. Rs.1,04,270/- and also compensation i.e. total of Rs.2,04,270/-.

          On the contrary op by filing written statement submitted that complainant’s proposed Super Top Up Mediclaim Policy was for the first time started on 30.03.2009 for self (66 years) and Bimala Devi Kothari (63 years) and it was renewed in the 3^rd year vide policy No.030200/48/10/36/00004995 valid from 30.03.2011 to 29.03.2012.  It is further submitted that during 3^rd  year policy period complainant undergone treatment of Osteoarthritis both knees and expenses incurred for the replacement of knees and the complainant claimed Rs.5,57,063/- and out of that Rs.4,50,000/- was reimbursed by the op and balance sum of Rs.1,07,063/- pending as per terms of Super Top Up Policy condition.

          It is further submitted that complainant claimed the balance amount of Rs.1,07,063/- to the op on 12.03.2012 and op duly forwarded the claim to the op no.2 Heritage Health TPA Pvt. Ltd. for scrutinizing the claim under Super Top Up Policy and on scrutinization of the claim op no.2 sent a letter on 26.04.2012 to the complainant asking for some documents.  Thereafter complainant replied vide their letter dated 10.05.2012 and that op again sent a letter on 31.05.2012 asking the complainant for submitting 1) confirmatory certificate from the treating doctor regarding duration of Osteoarthritis and 2) copy of 1^st prescription relating to consultation for osteoarthritis.  But the op no.2 again issued final reminder dated 12.06.2012 but the complainant intentionally did not provide the documents till date for settlement of the balance claim under Super Top Up Policy.

          So, it is clear that the balance claim of the complainant is still pending for non-cooperation of the complainant and non-submission of those documents at the time of taking Super Top Up Policy intentionally complainant did not disclose about his knowledge regarding his disease i.e. osteoarthritis and procured the policy in order to defraud the insurance company and thus violates policy condition of Super Top Up Policy and for which the complainant has miserably failed to establish the deficiency and negligent on the part of the op by any means and the complaint should be dismissed.

                                                  Decision with reasons

          After hearing the Ld. Lawyers of both the parties and considering the entire fact it is found that first two year of the policy period complainant was under gone treatment of osteoarthritis of both knees and expense was incurred by the complainant to the extent of Rs.5,57,063/- and out of that Rs.4,50,000/- have been reimbursed by the op and about balance claim of Rs.1,07,063/-, op submitted that at the time of taking the said Super Top Up Policy on 30.03.2009, complainant did not disclose that he had been suffering from osteoarthritis in his both legs in the Proposal Form.  Knowing fully well if it would be placed in that case his policy should not be accepted by the op.

          Fact remains that op no.2 sent letter on 31.05.2012 asking the complainant for supplying 1) confirmatory certificate from the treating doctor regarding duration of Osteoarthritis and 2) copy of 1^st prescription relating to consultation for osteoarthritis.  But anyhow complainant has miserably failed to produce any such document that he sent those documents to the op no.2 for settlement.  We have gone through the documents and materials but we have gathered that complainant did not submit the same for which it is still pending and that is stated by the op in the written statement.  Then it is clear that there was no fault, no deficiency, negligence on the part of the op for settlement of the balance claim. 

          Fact remains that complainant is not willing to file the same because no replacement of knee can be made if any person does not suffer from osteoarthritis for long years and if those documents would be submitted by the complainant in that case the claim of the complainant may be rejected on the ground that it was a pre-existing disease and only for that without submitting those documents to the op as per requirement of the op, the complainant appeared before this Forum to get justice.

          But we have gathered that this complaint is not honest in his approach in view of the fact the op already disbursed Rs.4,50,000/- out of amount spent to the extent of Rs.5,57,063/- and that was disbursed on humanitarian ground.  But in respect of balance amount two papers were required to be filed by the complainant but complainant did not file it and for which it is pending.  Then there is no deficiency and negligence on the part of the op but negligent and deficiency is on the part of the complainant who did not submit the same and complainant has miserably failed to prove that he has submitted it.  No copy has been submitted by the complainant in this Forum also.

          Considering all the above facts we are convinced to hold that there is no negligence and deficiency on the part of the op and as per provision of law it must be proved by the consumer otherwise the complaint may be rejected by the Forum.  Considering all the above fact and circumstances, we are convinced to hold that there is no negligence or deficiency on the part of the op, but all deficiency and negligent are on the part of the complainant which is proved because complainant has not yet complied the letter dated 31.05.2012 by sending confirmatory certificate from the treating doctor regarding duration of osteoarthritis and copy of 1^st prescription relating to consultation for osteoarthritis.  When it is the duty of the complainant to supply those documents otherwise no claim can be decided.

          In the result, we dismiss this complaint with a direction to the complainant to produce those documents as required by the op on the basis of their letter dated 31.05.2012 and if same shall be supplied by the complainant within one month from the date of this order, op shall have to decide it and if it is not supplied then claim of the complainant in respect of balance amount shall be treated as finally repudiated.

          Hence, it is

                                                           ORDERED

          That the complaint be and the same is dismissed on contest without any cost against the op.

          But ops are directed to dispose of the pending matter related to balance amount if complainant submits the particular two documents as per letter dated 31.05.2012 within one month from the date of this order and finally report to the complainant about the fate of the same but if it is found that complainant has not submitted those documents as referred in the letter of op dated 31.05.2012 within one month from the date of this Forum’s order in that case the said claim shall be treated as finally cancelled and complainant shall have no legal authority to file any further case.

          But if it is filed within the stipulated time in that case op shall have to dispose the same within one month from the receipt of the same documents and report to the complainant.