CONSUMER DISPUTES REDRESSAL FORUM, DISTRICT NORTH-EAST
D.C.(North-East) OFFICE COMPLEX, NAND NAGRI, DELHI
No.103/08
Sh. Sanjeev Joshi,
B-5041, PNO Society,
Sector 62, Gautam Budh Nagar,
Uttar Pradesh. : Complainant.
Versus
The New India Assurance Co.Ltd.
1/704, G.T.Road, Shahdara,
Delhi-32. : Opposite Party-I
Vipul Medcorp Pvt.Ltd.
5/15, Udhyog Vihar, Phase-V
Gurgaon, Haryana-122016 : Opposite Party-II
Order
MRS. ASHA KUMAR, MEMBER
In brief, complainant is a resident of Gautam Budh Nagar obtained mediclaim policy Hospitalisation/domicitrary bearing No. 320301/48/06/20/70001315 valid from 4.1.2007 to 3.1.2008 vide receipt dated 2.1.2007 No. 320301/81/06/0000011263 which was renewed from the year 2005. In that behalf OP-II issued identity card bearing No. 11A00059714 and the complainant is entitled to all the benefits under the aforesaid policy.
The complainant got admitted in Kailash Hospital and Research Centre Ltd. from 14.3.2007 to 18.3.2007 for the Chronic Renal Failure and underwent number of tests for dialysis and incurred huge amount in toto Rs.1,68,552/- for the treatment. The complainant informed the OP-I and bills were submitted in time but the claim of the complainant is still pending because of certain queries with respect to the report of Kidney Function Test done in September, 2006 etc. As per allegations complainant after furnishing the entire queries the claim has not been settled till yet. A legal notice dated 17.1.2008 was also served to the OPs. Hence the present complaint where in he has requested for Rs.1,68,552/-
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towards medical expenditures and Rs.50000/- as compensation. He further requested for Rs.3,00,000/- due to negligence and carelessness of the OP for treatment. In toto he requested for Rs.4,68,552 besides any other relief Hon’ble Forum deem fit.
On Notice, the OP appeared an filed his W.S.. In the WS filed by the OP, preliminary plea projected were that present complaint involves disputed question of facts so not maintainable in the Forum. Further mentioned that the Mediclaim Policy is based on proposal form and the claim of complainant is pending due to non completion of papers. Annexure-G which discloses the disease as well as expenses per month shows that the complainant was suffering from Diabetes mellitus with Hypertension Chronic Renal Failure, ‘pre-existing diseases’. Therefore, the claim of the complainant is not tenable and liable to be dismissed with cost.
Both the parties have filed their sworn affidavits in evidence in support of their respective contentions.
They have been heard and documents on record perused.
Certain facts are not disputed. The complainant has been obtaining mediclaim policy bearing no. 320301/48/06/20/70001315 valid from 4.1.2007 to 3.1.2008 and was renewed from the year 2005. The complainant got admitted in Kailash Hospital & Research Centre Ltd., Noida from 14.3.2007 to 18.3.2007 for Chronic Renal Failure and underwent number of tests for dialyses.
In the report of Kailash Hospital (Annexure-G, dtd. 15.3.2007), the complainant is suffering from Diabetes Mellitus with hypertension and Chronic Renal Failure and need life long regular dialysis twice per week and various medications to sustain his life. Prior to this, the complainant underwent in the same hospital in September, 2006 for treatment and the patient is known case of end stage of renal disease. For the settlement of the claim, the OPs
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requested for the reports of Kidney Function Test which was done in the year 2006. But the complainant deliberately suppress and never sent the papers to the OPs. It is because of suppression of material facts on the part of complainant, when he obtained the insurance cover from the OPs, he is suffering from the disease which is pre-existing. So we are of the opinion that OPs were fully justified in settling the claim of the complainant, without all the queries which complainant is not ready to disclose. As such OPs are not guilty of any deficiency in service and so present complaint fails. The same is ordered to be dismissed. But in view of the peculiar circumstances of the case, the parties are left to bear their own cost.
A copy of this order be sent to the concerned quarters by registered post or be supplied free of cost, on demand. File be consigned after compliance.
Announced on _____________________.
(U.C.Tiwari) (Asha Kumar)
President Member
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