STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA
Date of Institution: 26.11.2018
Date of final hearing: 11.05.2023
Date of pronouncement: 30.05.2023
First Appeal No.1285 of 2018
In the matter of :-
Sunder Pal Singh son of Sh. Rohtash Singh, resident of H.No.B-1, Govinderpur Modi Nagar, Ghaziabad at present Metro Hospital and Heart Institute Circular Road, Rewari, District Rewari, Haryana. .…..Appellant
Versus
- Star Health and Allied Insurance Company ltd. Registered & Corporate Office at New Tank Street, ValluvarKottam High Road, Nunganbakkam, Chennai-600034.
- Jitender Madan, Financial Consultant, residing within campus building of Indra Gandhi University, Meerpur, Tehsil and District Rewari.
- Manager, Star Health and Allied Insurance Co. Ltd. having its office in the building of Late Col. Maha Singh, Krishna Nagar, Col. Maha Singh Marg, Rewari. …..Respondents
CORAM: Naresh Katyal, Judicial Member
Argued by:- Sh.J.S. Yadav, Advocate for the appellant.
Sh. Ravinder Arora with Sh. Sudhir Gupta, Advocate for respondent No.1& 3.
Presence of respondent No. 2 dispensed with being profoma respondent.
ORDER
NARESH KATYAL, JUDICIAL MEMBER:
Sunder Pal Singh-complainant, being unsuccessful, has filed this appeal and assailed legality of order dated 31.10.2018 passed by District Consumer Disputes Redressal Forum, Rewari(In short “District Commission”) in complaint case No. 356 of 2015, vide which his complaint has beendismissed.
2. Complainant held health Insurance Policy of opposite party effective from 09.07.2013 to 08.07.2014. He suffered chest pain in the night of 31.12.2013. Being an employee of Metro Umkal Hospital and Heart Institute Circular Road, Rewari he visited there. After, conducting his ECG, he was admitted on 01.01.2014. He was diagnosed as:Unstable Angina, CAG, DVD (double vessle disease) LCX-90%, LAD 80% PTCA/stenting to LCX on 03.01.2014 and LVEF 50%. He paid Rs.2,87,375/- to hospital vide receipt dated 25.02.2014.He lodged claim with opposite parties which, as per allegations, was illegally and wrongly declined. He filed appeal which was dismissedwrongly and illegally on 29.06.2015 by Insurance Ombudsman NoidaWestern UP and Uttrakhand. On these, allegation he filed complaint before District Commission for issuance of direction to OPs to compensate him with amount of Rs.2,87,375/- incurred by him with interest @12% from 01.01.2014 till realization. He also claimedcompensation of Rs.1,00,000/- with interest @12% for mental agony and pain. He has also claimed Rs.25,000/- as cost of litigation.
3. Opposite Parties raised contest.In their defence; it is pleaded that complainant is himself Deputy General Manager of Metro Umkal Hospital, Dharuhera Chowk, Rewari for last two years. Complaint is frivolous and vexatious. Swastik Medi Service was appointed to investigate the case. Investigator’s report is dated 17.01.2014. According to hospital’s adult in-patient record dated 01.01.2014; insured was admitted at 10:00 AM on 01.01.2014. As per medical certificate issued by treating Doctor, patient was admitted at 2:30 PM at 01.01.2014. Insured patient was on duty on 05.01.2014, but as per Hospital’s record and discharge summary; insured patient remained admitted in hospital, as in-patient, till 06.01.2014. As per insured’s self declaration, he has not paid bill to hospital, so no question arises for reimbursement. Insurer issued repudiation letter 24.02.2014. It is further pleaded that complainant has not disclosed any disease at the time of purchasing policy. Investigator, during investigation found that complainant was having pre-existing disease and he fabricated the claim amounting to non-disclosure of material facts. Complainant breached the Medi-claim policy which was rightly cancelled by company on 15.04.2014, and this fact has been intimated to complainant vide letter dated 19.04.2014. Premium paid by complainant have already been returned to him vide DD No. 447458 dated 19.04.2016 for Rs.7,382/-. On merits, insurer has denied averments of complaint and prayed for its dismissal.
4. Parties to this lisled evidence, oral as well as documentary. On analyzing the same learned District Commission has dismissed the complaint vide dated 31.10.2018. Feeling dissatisfied, appellant has filed this appeal.
5. I have heard learned counsel for the appellant and learned counsel representing opposite parties No. 1 and 3 at length. With their assistance the record of learned District Commission has also been perused.
6. On behalf of appellant, it is contended that:notwithstanding the fact complaint was serving with Metro Umkal Hospital and Heart Institute Rewari, yet he obtained treatmentfrom that Hospital from 01.01.2014 to 06.01.2014. His claim for reimbursement of amount spent by him on his treatment has been wrongly declined by insurer vide its letter dated 24.02.2014. It also urged that claimant was not having any pre-existing disease before the inception of policy. He unsuccessfully approached Insurance Ombudsman and his claim too was declined there on wrong notion.
7. On the other hand, learned counsel for insurer has supported the repudiation letter dated 24.02.2014 and urged that claimant’s complaint has been rightly rejected by learned District Commission through order dated 31.10.2018.
8. Complainant landed in Metro Umkal Hospital and Heart Institute on 01.01.2014;he was discharged on 06.01.2014, as per discharge summary (Ex. CW-1/33).During tenure of claimant’s indoor hospitalization; he underwent good number of medical tests, so deciphered from his treatment record.There are threePathology reports viz: dated 04.01.2014 (Ex. CW1/28), dated 05.01.2014 (Ex. CW1/27) and dated 06.01.2014(Ex. CW1/26).Admittedly, being Deputy General Manager of the Hospital, he was on duty in Hospital on 05.01.2014 whereas, in sheer contradistinction he (complainant)remained admitted as indoor patient in same hospital, till 06.01.2014. It is quite mysterious and mystifying circumstance, which has created hallmark of difference to non-suit the complainant. Learned counsel forcomplainant/appellant could not put across any evidence before this Commission during the course of arguments in this appeal, in order to wriggle out from adverse legal ramifications so flowing from above factual scenario. Claimant’s claim has been repudiated by the insurer vide letter dated 24.02.2014.
9. Undisputedly, claimant filed complaint under Rule 16 of the Redressal of Public Grievances Rules, 1998 before Insurance Ombudsman against rejection of his claim by insurance company. His complaint too has been declined by the order dated 29.06.2015 (Ex.CW-1/1) passed by Insurance Ombudsman on the ground that claim is false and fabricated. Order dated 29.06.2015, still holds the light of its day. Nothing has been shown to this Commission that aggrieved complainant has ever questioned the legality of decision dated 29.06.2015 of Insurance Ombudsman before any Appellate Authority. Once, complainant has chosen to file complaint before Insurance Ombudsman and was unsuccessful, then he cannot thereafter, knock the doors of District Consumer Commission by filing separate complaint on 16.10.2015.
10. In view of above critical discussion; this Commission does not notice any illegality in the impugned order dated 31.10.2018 passed by District Consumer Commission Rewari. Complainant has been rightly non-suited. Order dated 31.10.2018 is maintained and affirmed. This appeal being devoid of merits is hereby dismissed.
11. Applications pending, if any stand disposed off in terms of the aforesaid judgment.
12. A copy of this judgment be provided to all the parties free of cost as mandated by the Consumer Protection Act, 1986/2019. The judgment be uploaded forthwith on the website of the Commission for the perusal of the parties.
13. File be consigned to record room.
Date of pronouncement: 30th May, 2023
Naresh Katyal
Judicial Member
Addl. Bench-II
D.K
