Haryana

Ambala

CC/61/2021

Vikas Kumar - Complainant(s)

Versus

Reliance General Insurance Co - Opp.Party(s)

Naresh Sharma

24 Mar 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

Complaint case no.	:	61 of 2021
Date of Institution	:	01.02.2021
Date of decision	:	24.03.2023

 

Vikas Kumar son of Sh.Desh Deepak, resident of Village Kherki Jattan, Kherijatan, District Ambala, Haryana.

          ……. Complainant.

Versus

Reliance General Insurance, 1-89/3/B/40 to 42/ks/301, 3rd Floor, Krishe Block, Krishe Sapphire, Madhapur, Hyderabad-500081 through its authorized signatory.

….…. Opposite Party

Before:        Smt. Neena Sandhu, President.

                             Smt. Ruby Sharma, Member,

          Shri Vinod Kumar Sharma, Member.           

 

Present:        Shri Naresh Sharma, Advocate counsel for the complainant.    

                    Shri Mohinder Bindal, Advocate, counsel for OP.

Order:        Smt. Neena Sandhu, President.

1.                Complainant has filed this complaint under Section 35 of the Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the Opposite Party (hereinafter referred to as ‘OP’) praying for issuance of following directions to it:-

i) To pay an amount of Rs.37,570/- (expenses of treatment incurred by the complainant) along with interest, till its realization.

ii) To pay a sum of 50,000/- on account of loss, harassment, pain, agony suffered by the complainant.

iii) To pay Rs.21,000/- as litigation expenses.

                                      OR

Grant any other relief which this Hon’ble Commission may deems fit.

 

2.             Brief facts of the case are that the complainant is having bank account bearing no.097099600001123 in the Yes Bank Ltd. Ground Floor, Chandigarh Chowk, Nariangarh, District Ambala. The said bank had insured the complainant with the OP  vide UHID No.28282190049808, Policy No.785321928280000064, valid upto 9.7.2020 for which the complainant paid an amount of Rs.7300/- as premium. The OP also issued LiveSmart card in favour of the complainant. The OP also covered the complainant and his wife Smt. Sonia Devi under the policy in question, which provided Rs.3 Lakh cashless health insurance to them. On 9.3.2020 the complainant fell ill due to stomach inflection and was admitted in J.P. Hospital, Near Luxmi Cinema, Jagadhri Road, Ambala City, Haryana for his treatment, where he was remained admitted upto 12.3.2020. The complainant contacted the OP on its toll free number 1800 3009 and narrated the true facts in this regard. The officials of the OP assured the complainant that the company will pay the full cashless amount to the said hospital. On 12.3.2020 i.e. date of discharge, when the complainant again contacted the OP for making payment of Rs.37,570/- incurred on his treatment, he was asked to pay the same and that he can claim it later on from the OP. Resultantly, the complainant paid the said amount from his pocket. Thereafter, despite the fact that all requisite documents were provided by the complainant to pay the amount which the complainant incurred on his treatment but to no avail. Left with no alternative, the complainant also served a legal notice dated 2.9.2020 upon the OP but the same was not even replied. By not paying the medical expenses incurred by the complainant for his treatment, the OPs have committed deficiency in service. Hence this complaint.
3.           Upon notice, the OP appeared and filed written version and raised preliminary objections with regard to jurisdiction, cause of action and maintainability etc. On merits, it has been stated that the complainant by concealing and suppressing true and material facts about pre-existing ailment, as stated in entire treatment records of the M M Institute of Medical Sciences & Research that he is a known case of burning Micturition for the last 10- 15 years with frequency of micturition in day time after every ½  to 1 hrs. and in night hours for 2-4 times and other urinary problems and all these problems have been only due to Horseshoe Kidney structure of the complainant which is his by birth disease. The complainant procured the alleged insurance policy illegally by cheating the OP with the sole aim to extract compensation from it.  Since the complainant has intentionally and deliberately concealed and suppressed the material facts about his pre-existing ailment of kidney and urinary related problems to take illegal benefits of policy from the OP, hence the claim was rightly and legally held not maintainable and payable. Moreover, also the alleged ailment and treatment availed by the complainant was not supposed to be availed as an indoor patient but was an outdoor treatment as M M Hospital had prescribed to the complainant and he had been under continuous treatment since  long time. After scrutinizing the entire treatment record and finding multiple discrepancies, the OP repudiated the claim of the complainant by treating it a fraudulent claim under clause 5.10 of the policy. The complainant was duly informed about the fate of his claim vide letter dated 13.11.2020 but the complainant in order to put undue pressure has filed this false complaint by exploiting the process of law. Rest of the averments of the complainant were denied by the OP and prayed for dismissal of the present complaint with costs.
4.           Learned counsel for the complainant tendered affidavit of the complainant as Annexure CA alongwith documents as Annexure C-1 to C-25 and closed the evidence on behalf of the complainant. Learned counsel for the OP tendered affidavit of Surya Deep, Authorized Signatory, Reliance General Insurance Co. Ltd., Registered office, Chandigarh as Annexure OP-A alongwith documents Annexure OP-1 to OP-7 and closed evidence on behalf of the OP.
5.           We have heard the learned counsel for the parties and have also carefully gone through the case file.
6.           Learned counsel for the complainant submitted that by repudiating the genuine claim of the complainant, despite the fact that treatment was taken by him, during subsistence of the policy in question, the OP is deficient in providing service and that the complainant is entitled to get back his money, incurred on his treatment aforesaid.
7.           On the other hand, learned counsel for the OP submitted that since the complainant had concealed the material fact with regard to his pre-existing ailment, as stated in entire treatment records of the M M Institute of Medical Sciences & Research wherein it was clearly mentioned by the doctor that the complainant is a known case of burning Micturition for the last 10- 15 years with frequency of micturition in day time after every ½  to 1 hrs. and in night hours for 2-4 times and other urinary problems and all these problems have been only due to Horseshoe Kidney structure of the complainant which is his by birth disease but the complainant procured the insurance policy illegally by concealing the same, as such, his claim was rightly repudiated by the OP  vide letter dated 13.11.2020.
8.           To prove its case, the OP has placed on record treatment records of the M M Institute of Medical Sciences & Research, Annexure OP-4 dated 02.03.2020, which shows that the complainant was having disease named burning Micturition for the last 10- 15 years with frequency of micturition in day time after every ½  to 1 hrs. and in night hours for 2-4 times and other urinary problems due to his Horseshoe Kidney structure. Not only as above, the OP has also placed on record treatment record of the complainant Annexure OP-5 taken by him in the J.P. Hospital for the period from 07.03.2020 to 12.3.2020, wherein also it has been clearly mentioned by the doctor that the complainant was suffering from Recurrent UTI. However the complainant has not placed on record the above mentioned treatment record.
9.           It is significant to mention here that perusal of part record Annexure C-3 placed on record by the complainant reveals that the chief complaints made by him in J.P. Hospital was Fever, pain abdomen, sweating and no passing of urine from 5 to 7 days. We have gone through the literature provided by learned counsel for the OP qua complications of Horse Shoe Kidney and found that urinary tract infection, pain in the belly and abdomen, nausea, kidney stones etc. are some of the complications faced by the persons having such Horse Shoe Kidney. 
10.           No plausible reason whatsoever has been given by the complainant, as to why, he failed to place on record the crucial documents, referred to above, before this Commission i.e. Annexure OP-4 (issued by M M Institute of Medical Sciences & Research) wherein it was written that the complainant was having disease named burning Micturition for the last 10- 15 years with frequency of micturition in day time after every 2 to 1 hrs. and in night hours for 2-4 times and other urinary problems due to his Horseshoe Kidney structure and also Annexure OP-5 (issued by J.P. Hospital) wherein it has been clearly mentioned by the doctor that the complainant was suffering from Recurrent UTI. It may be stated here that it is settled law that a person who approaches the Court for granting relief, equitable or otherwise, is under a solemn obligation to candidly & correctly disclose all the material/important facts which have bearing on the adjudication of the issues raised in the case. He owes a duty to the court to bring out all the facts and desist from concealing/suppressing any material fact within his knowledge or which he could have known by exercising due diligence expected of a person of ordinary prudence. The Hon’ble Supreme Court in  Union of India and others v. Muneesh Suneja (2001) 3 SCC 92; Sunil Poddar and others v. Union Bank of India (2008) 2 SCC 326 and G. Jayshree and others v. Bhagwandas S. Patel and others (2009) 3 SCC 141 has repeatedly invoked and applied the rule that a person who does not disclose all material facts has no right to be heard and can be thrown out at any stage.  In LIC of India Vs. Manish Gupta, Civil Appeal No.3944 of 2019 relied upon by learned counsel for the OP also, the Hon’ble Supreme Court has held that repudiation of claim on the ground of suppression of material information regarding disease by the insured cannot be said to be invalid. 
11.           In this view of the matter, it is held that since the complainant has not placed on record his entire medical records especially, Annexure OP-4 (issued by M M Institute of Medical Sciences & Research) and  Annexure OP-5 (issued by J.P. Hospital), referred to above, deliberately, as such he does not deserve any relief from this Commission. Resultantly, this complaint stands dismissed with no order as to cost. Certified copies of the order be sent to the parties concerned as per rules.  File be annexed and consigned to the record room.

 Announced:- 24.03.2023

 

(Vinod Kumar Sharma)	(Ruby Sharma)	(Neena Sandhu)
Member	Member	President