Mittar Singh vs NEW INDIA ASSURANCE CO. LTD.

THE present complaint has been filed by the complainant under Section 17 of the Consumer Protection Act, 1986 (hereinafter referred to as ''the Act'') averring therein that the complainant is a Credit Card holder of City Bank. THE City Bank in collaboration with O.P. No. 2 Insurance Company floated a Group Insurance Scheme (Medical) whereby the complainant was also eligible for a mediclaim policy under the said scheme. It is stated by the complainant that lured by the false representations of the opposite party, he applied for the grant of insurance policy under the Group Insurance (Medical) Scheme and paid a premium of Rs. 5,256/- by cheque, which was duly encashed by the O.Ps. who issued Insurance Policy No. 48/712500/7/04956/CS.97 dated 24.2.1997 valid for the period from 1.2.1997 to 31.1.1998 in favour of the complainant. THE complainant was thus insured with the O.P. for a sum of Rs. 5 lakhs against the said mediclaim policy.

ON the night of 15.5.1997, the complainant suffered pain in the left side of the back, and as such the complainant immediately contacted Dr. P.K. Maheswari, Senior Physician and Cardiologist at his Nursing Home, known as Vital Care Centre situated at A-1, Ground Floor, Building No. 20, Manish Nagar, 4 Bungalow, Andheri West Mumbai, where the complainant was kept overnight i.e. 15.5.1997 to 16.5.1997. Thereafter on carrying out various tests the complainant was diagnosed as a case of Angina and prescribed some medicines, he was also advised to be shifted to Dr. Balabhai Nanavati Hospital, Mumbai. It is the case of the complainant that the complainant had suffered such an ailment for the first time on 15.5.1997 and prior to that he had never had any heart problem. The complainant remained in the Balabhai Nanavati Hospital, Mumbai from 16.5.1997 to 25.5.1997 and various medical check-ups and treatments were carried out on the complainant during his stay in the said hospital. Thereafter on his discharge from the Balabhai Nanavati Hospital on 25.5.1997, the complainant was removed to Delhi to be taken care of by his family who were living at Delhi at the relevant time. ON 2.6.1997, the complainant again suffered pain in the chest and was rushed to Indraprastha Apollo Hospital, New Delhi on 4.6.1997 where he was admitted in the ICCU. At the said hospital, the complainant was attended upon by Dr. Hariharan, one of the reputed senior Physicians and Dr. Ganesh K. Mani, Heart Surgeon, who on carrying out various tests and investigations suggested that open heart surgery should be performed on the complainant, as he had double vessel disease. Thereafter the complainant underwent open heart surgery on 9.6.1997 and was discharged from Apollo Hospital on 18.6.1997. The complainant incurred expenditure as detailed in his complaint in respect of his treatment carried out at Mumbai, as well as, at Delhi and as such filed two separate claims with the O.P. for the same. However, despite having filed the claim forms along with all the relevant documents, the receipt of which was duly acknowledged by the O.P.-Company vide letter dated 20.10.1997, the claim of the complainant was delayed considerably and eventually rejected on the grounds of non-disclosure of pre-existing disease vide letter dated 16.3.1998. The complainant thereafter also followed up the matter for re-consideration of his claim and also requested for information regarding the basis for the rejection of his claim. In response to the said letter of the complainant dated 18.5.1998, the O.P. vide its letter dated 26.5.1998 informed the complainant that the claim of the complainant had been rejected on the basis of the case sheet of the Indraprastha Apollo Hospital. The complainant thereafter on inquiry from the Apollo Hospital learnt that somebody had falsely and unauthorisedly entered in his case history sheet dated 7.6.1997 that the complainant was suffering from Angina for one year and Dysnoea for the last five years. As such the complainant approached Dr. Ganesh K. Mani who had operated upon him and the said doctor at his request issued a certificate to the effect that the complainant had never suffered from any heart problem prior to 15.5.1997. In pursuance of the said certificate issued by Dr. Ganesh K. Mani, the complainant again approached the O.P. vide his letter dated 6.7.1998 pointing out all the aspects of the case including the above mentioned certificate issued by the Dr. Ganesh K. Mani but since no response to the same was received from the side of the O.P. despite various reminders, the complainant approached this Commission by filing the present complaint claiming a sum of Rs. 8,79,071/-, as per details provided in paras 38 and 39 of the complaint, together with interest at the rate of 18 per cent per annum and costs. The O.P. was served a notice by registered post on 12.6.2000 which was not received back undelivered and as such service of the said notice on the O.P. was presumed and the O.P. was afforded an opportunity of four weeks for filing written statement/written version. Thereafter another opportunity was also afforded to the O.P. for the aforesaid purpose vide order/proceedings dated 30.4.2001. However, since none appeared on behalf of the O.P. nor filed any reply/written version to the complainant, the O.P. was directed to be proceeded ex parte vide order/proceedings of this Commission dated 7.9.2001. The complainant filed his own affidavit by way of evidence along with relevant documents.

We have carefully perused the evidence and the documents/material placed on record. We have heard the complainant at length and have also deliberated upon the written submissions filed on behalf of the complainant. From the material on record, it is apparent that the complainant had obtained a mediclaim policy from the O.P., valid for the period 1.2.1997 to 31.1.1998. During the said period, the complainant was hospitalised twice and also underwent treatment and surgery for his heart ailment. The complainant filed two separate claims with the opposite party/Insurance Company for the expenditure incurred for his treatment at Bombay and Delhi. The opposite party however rejected his claims on the ground of non-disclosure of pre-existence of his heart ailment. However, the case history pertaining to the treatment of the complainant under the care of Dr. P.K. Maheswari of Vital Care Centre, Mumbai (Ex. C.W. 1/2) and the brief history recorded at the Indraprastha Apollo Hospital (Ex. C.W. 1/12) does not anywhere state that the complainant had any history of heart problem prior to the occurrence of the pain on 15.5.1997. On the contrary, in the brief history recorded by the Indraprastha Apollo Hospital (Department of Cardiac Surgery) Exhibit C.W. 1/12 along with affidavit of Shri Mittar Singh, complainant specifically states that there is no history of dysnoea/palpitation/syncope/TIA and there is no history of any drug allergy or previous surgery. The O.P. has rejected the complainant''s claim on the basis of the examination report prepared at Indraprastha Apollo Hospital, according to which the complainant is supposed to be having Angina for the last one year and dysponoea on exertion for the last five years. The complainant in his affidavit by way of evidence has specifically stated that the said observations in the case sheet have been entered unauthorisedly and illegally and that he has never had any heart problem prior to the incident in question. Furthermore, the complainant has also placed on record a copy of the form duly filled by the attending doctor, Dr. Ganesh K. Mani, Department of Cardiac Surgery, Indraprastha Apollo Hospital and addressed to the Insurance Company/O.P. (C.W. 1/45) stating therein that the complainant was suffering from unstable Angina only for the last one and half months. It is also the case of the complainant that the specific certificate to the said effect was also issued by the concerned doctor which was forwarded in original to the opposite party, and despite that the O.P. has refused to reconsider his claim. Not only that, though the claim of the complainant in respect of his hospitalisation and treatment and expenditure incurred at Delhi was lodged with the O.P. on 30.5.1997 and in respect of treatment and expenditure incurred at Bombay on 13.8.1997, the opposite party had rejected his claim vide letter dated 16.3.1998 after considerable delay and reminders on the part of the complainant. From the facts on record, it is apparent that not only has the O.P. been deficient in service in taking a decision in respect of the claims of the complainant after considerable delay but the O.P. has also not taken into consideration the relevant documents placed before it by the complainant before rejecting his claim. Thus the claim of the complainant duly supported by all the documents the receipt of which is duly acknowledged by the O.P. vide letter dated 20.10.1997, has been rejected by the O.P. without due application of mind and as such the same amounts to deficiency in service on the part of the opposite party. Furthermore, the O.P. has neither bothered to appear nor bothered to file any reply or evidence to rebut the case put up by the complainant. On the other hand the complainant has filed the bills and receipts of the expenditure incurred on treatment and medicines, as well as, other relevant documents to support his claim.

IN the presence of the above facts, the complainant is entitled to the relief as claimed and as such the O.P. is directed to reimburse to the complainant the amount spent by him on his treatment and hospitalization amounting to Rs. 4,13,636/- with interest at the rate of 12 per cent per annum from the date of the presentation of the claim till actual payment. Since we have already awarded interest on the amount claimed, the complainant is not entitled to any further compensation. However, the complainant is entitled to the cost of the present litigation, which is fixed at Rs. 5,000/-. The amounts awarded as per this order are to be paid by the O.P. within 45 days of the receipt of the order. The present complaint stands disposed of in above terms. Complaint disposed of.