Padma Pandey, Member:
1. This appeal is directed against the order dated 03.02.2014, rendered by the District Consumer Disputes Redressal Forum-II, UT, Chandigarh (hereinafter to be called as the District Forum only) vide which, it allowed the complaint filed by the complainant and directed the Opposite Parties (now appellants) as under:-
œ10. In the light of above observations, we are of the concerted view that the Opposite Parties are found deficient in giving proper service to the complainant. Hence, the present complaint of the Complainant deserves to succeed against the Opposite Parties, and the same is allowed, qua them, jointly and severally. The Opposite Parties are directed to:-
[a] To reimburse the remaining claim amount of Rs.1,51,201/-;
[b] To pay compensation of Rs.15,000/- on account of deficiency in service;
[C] To pay Rs.7,000/- as cost of litigation;
11. The above said order shall be complied within 45 days of its receipt by the Opposite Parties; thereafter, they shall be liable for an interest @18% per annum on the amount mentioned in sub-para [a] and [b] of para 12 above, apart from cost of litigation of Rs.7,000/-, from the date of institution of this complaint, till it is paid?.
2. In brief, the facts of the case, are that the complainant obtained a PNB Oriental Royal Mediclaim Policy from the Opposite Parties, which he continued to renew from time to time and currently, the same was valid from 13.07.2012 to 12.07.2013 covering himself and his wife for a sum assured of Rs.5.00 lacs (Policies C-1, C-1/A and C-1/B). It was stated that during the currency of the policy, the complainant felt breathlessness on 12.3.2013, and was evaluated at Nohria Nursing Home, from where he was referred to Alchemist Hospital, where he remained admitted upto 18.3.2013 and spent Rs.67,410/- for treatment of kidney and Rs.1,51,201/- for treatment of Advanced Renal Failure, Bilateral Nephrolithiasis, Bilateral Hydronephrosis (Bills and discharge summary Annexure C-2(colly) and C-3). Accordingly, the complainant, lodged a claim with the Opposite Parties (Annexure C-4 and C-4/A). However, the Opposite Parties paid the claim for treatment of kidney but rejected the claim for treatment of Bilateral Nephrolithiasis, Bilateral Hydronephrosis vide letter dated 9.6.2013 by referring to Exclusion Clause 4.1 of the Policy. It was further stated that the Opposite Parties were deficient, in rendering service, as also, indulged into unfair trade practice. When the grievance of the complainant was not redressed, left with no alternative, a complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter to be called as the œAct? only), was filed.
3. In their written reply, the Opposite Parties, while admitting the factual matrix of the case stated that the complainant was covered under the Insurance Policy, which was running in the third year from the date of inception of the same. It was further stated that as the same had not completed the period of three years by virtue of which the pre-existing diseases, existing at the time of inception of the first policy would have been covered, the present claim being the result of pre-existing disease existing prior to the inception of the policy, was not payable and the claim of the complainant was rightly repudiated vide Annexure C-5 explaining clear reasons for the same and after due application of mind and after seeking opinion from the medical expert/ doctor. It was further stated that, therefore, there was no deficiency in service on their part. It was further stated that the complainant had concealed the material fact that he had been suffering from the disease/ailment hypertension for the last ten years, which was a leading cause of Renal Failure due to which he was hospitalized and the said fact was mentioned by the doctor concerned in the Progress Note dated 13.3.2013 of Alchemist Hospital prepared by him at the instance of the Complainant (Annexure R-1). It was further stated that by not adhering to the principle of good faith and concealing the said fact of pre-existing disease, the complainant rendered his claim as non-payable. It was further stated that the Opposite Parties were neither deficient, in rendering service nor indulged into unfair trade practice.
4. The Parties led evidence, in support of their case.
5. After hearing the Counsel for the parties, and, on going through the evidence and record of the case, the District Forum, allowed the complaint, as stated above.
6. Feeling aggrieved, the instant appeal, has been filed by the appellants/Opposite Parties.
7. We have heard the Counsel for the appellants/Opposite Parties, and have gone through the evidence and record of the case, carefully.
8. The Counsel for the appellants/Opposite Parties submitted that the District Forum erred in not relying upon Ex.R-1 produced by the appellants/Opposite Parties, and in relying upon Annexures Ex.C-7 and Ex.C-8 produced by the respondent/complainant. He further submitted that the complainant concealed the material fact that he had been suffering from the disease/ailment hypertension for the last ten years, which was a leading cause of Renal Failure due to which he was hospitalized and the said fact was mentioned by the doctor concerned, in the Progress Note dated 13.3.2013 of Alchemist Hospital prepared by the doctor concerned at the instance of the complainant (Annexure R-1) and, as such, the order of the District Forum is liable to be set aside. This submission of the Counsel for the appellants is not tenable, in the eye of law, especially when the complainant produced, on record, two certificates i.e. Annexure C-7 and Annexure C-8 respectively, which were issued under the hand of the treating Doctor, and were duly signed and stamped by him. The treating doctor, in these certificates, clearly stated that the complainant did not have any past history of hypertension, diabetic mellitus, Coronary Arterial Disease, Renal Failure etc., meaning thereby that the stand of the Opposite Parties, that the complainants condition of Acute Renal problems was on account of hypertension was incorrect. The aforesaid certificates were duly supported by the affidavit of the treating doctor namely Dr.Rajiv Goyal, M.Ch (Urology).
9. In this view of the matter, we are of the considered view that the District Forum was right in placing reliance on the certificates i.e. Annexures C-7 and C-8, which were supported by the affidavit and ignoring Annexure R-1 relied upon by the appellants.
10. The District Forum was also right in holding that the Opposite Parties while allowing a partial claim of the complainant and denying him the remaining amount of Rs.1,51,201/- and that too on feeble and baseless observations, certainly amounted to deficiency in rendering service on the part of the appellants. Thus, the order of the District Forum, being legal, is liable to be upheld. The order passed by the District Forum, does not suffer from any illegality or perversity, warranting the interference of this Commission.
11. For the reasons recorded above, the appeal, being devoid of merit, must fail, and the same is dismissed in limine, with no order, as to costs. The order of the District Forum is upheld.
12. Certified Copies of this order be sent to the parties, free of charge.
13. The file be consigned to Record Room, after completion.