This revision is directed against the order of the Haryana State Consumer Disputes Redressal Commission, Panchkula (in short, 'the State Commission') dated 21.9.2016 in first appeal No.192/2016 whereby the State Commission concurred with the order of the District Forum, Sirsa and dismissed the appeal.
2. Briefly stated, facts relevant for the disposal of the revision petition are that the complainant/respondent No.1 purchased a medi-claim insurance policy from the petitioner/insurance company on payment of premium. The policy promised cashless treatment in the event of any ailment subject to the terms & conditions. The policy was effective w.e.f. 28th March, 2012 till 28th March, 2015. M.D. India Healthcare Services (TPA) Pvt. Ltd. was third party service provider under the aforesaid policy.
3. On 11.4.2013 the complainant developed pain in his chest. He approached Dr. Ajai Poonia who after preliminary examination referred the complainant to AIIMS for further management. The complainant, however, approached Medanta The Medicity, Gurgaon under intimation to opposite party No.3. Medanta hospital being a costly institute, the complainant went to Sri Balaji Action Medical Institute, Paschim Vihar, New Delhi where he remained from 21.4.2013 to 29.4.2013. The complainant incurred expense of Rs.1,75,280/- in Sri Balaji Action Medical Institute and Rs.36,716/- in Medanta hospital. It is the case of the complainant that he lodged his claim for cashless treatment with the petitioner insurance company which was forwarded to respondent No.3 TPA for settlement. The respondents, however, denied cashless treatment on the premise that there was a possibility of the complainant having concealed information about his previous ailments. It is further the case of the complainant that thereafter he approached the petitioner/respondent for settlement of his claim but the petitioner continued to put off the matter on one pretext or the other. The complainant, thus, served the petitioner with a legal notice dated 19.6.2013. Despite that the petitioner refused to settle the claim. Feeling aggrieved, the complainant raised a consumer dispute by approaching the District Forum, Sirsa.
4. The petitioner/opposite party resisted the complaint by filing written statement. According to the petitioner insurance company, it only rejected the request of the respondent/complainant for cashless treatment because there was a possibility of concealment of material facts by the complainant regarding his previous ailments. It is submitted that thereafter no claim was submitted and as such there is no cause of action for filing the complaint.
5. The District Forum on consideration of the pleadings and the evidence came to the conclusion that there was no concealment of fact on the part of the complainant and the opposite party was deficient in service. Complaint was therefore allowed and opposite party insurance company was directed to pay to the complainant sum of Rs.2,11,996/- with 9% interest thereon from the date of filing of the complaint till the realization, besides cost of Rs.2,000/-.
6. Being aggrieved of the order of the District Forum, the petitioner insurance company approached the State Commission in appeal. The State Commission on re-evaluation of evidence did not find any fault with the order of the District Forum. The appeal was accordingly dismissed. This has led to filing of the revision petition.
7. Learned counsel for the petitioner has contended that the impugned orders of the Fora below are not sustainable because the Fora below have failed to appreciate that the complainant had obtained the insurance policy by giving false information regarding his health status. In this regard, learned counsel for the petitioner has drawn our attention to the copy of the proposal form filled by the complainant on 28th March, 2012 wherein the complainant in response to the questionnaire pertaining to his health, particularly regarding heath ailment and diabetes mellitus has answered in the negative. Learned counsel has drawn our attention to the prescription issued by Poonia hospital on 11.4.2013 wherein the concerned doctor has recorded that the complainant visited his clinic with history of pain in chest and uneasiness and that the patient was advised ECG which showed some changes. There is also a mention about diabetes mellitus-2. This document, in our view, is of no avail to the petitioner insurance company because the document is of the date after the submission of the proposal form. Counsel for the petitioner has failed to show us any evidence which could lead us to the conclusion that prior to 28.3.2012 the complainant was found suffering from any heart ailment or diabetes mellitus. In absence of any such evidence, it cannot be said that the complainant has concealed material fact while purchasing the insurance policy. Thus, we do not find merit in the plea of the petitioner that the complainant/respondent No.1 entered into a contract by concealing information.
8. Learned counsel for the petitioner has further contended that in the instant case the opposite party insurance company had refused cashless treatment because of suspicion of concealment of fact on the part of the complainant. No insurance claim after the treatment was filed, therefore, the complaint itself is pre-mature. We do not find merit in this contention. It is not in dispute that the medi-claim policy issued to the complainant was a cashless policy. Therefore, there was an implied assurance on the part of the petitioner that in the event of the respondent/complainant suffering from any ailment, he would be given cashless treatment at the concerned clinic or hospital subject to the term
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s and conditions of the insurance policy. Counsel for the petitioner has failed to show us any document which could induce a reasonable person to suspect that the complainant has given wrong information in the proposal form about his previous medical condition. Therefore, in our view, the refusal of the petitioner to authorize cashless access to the respondent/complainant amounts to unfair trade practice. Thus, under the circumstances, we do not find any fault with the concurrent finding of the Fora below which may call for interference in exercise of revisional jurisdiction. 9. Revision petition is accordingly dismissed.