- (1.) THIS appeal is directed against order dated 15.03.10, passed by District Consumer Disputes Redressal Forum, Bilaspur (hereinafter called "District Forum" for short) in complaint case No. 191/04, whereby the complaint of the appellant herein seeking reimbursement of bills of Rs. 44,276/ - under medi -claim insurance policy issued by respondent Company and claim of damages of Rs. 50,000/ - on account of alleged deficiency in service, has been dismissed.
(2.) THE case of the complainant before District Forum was that he was continuously taking medi -claim insurance policy from the year 1998. Earlier such policies were taken from New India Assurance Co. Ltd. , up to 2003 and in the year 2003, he switched over from New India Assurance Co. Ltd. to United India Insurance Co. Ltd. for renewal of existing medi -claim policy. Respondent Company provided insurance cover for the period between 14.03.03 to 13.03.04, after receiving premium of Rs. 10,068/ - under the medi -claim policy. Later on, complainant suffered some ailments of eyes and preferred a claim before the insurance company on 24.12.03. The insurance company repudiated the claim on the ground that the complainant earlier had undergone surgical procedure for pterygium of left eye in the year 1969 and 1977 and after operation of 1977 he suffered photophobia also, but he has not provided information regarding all the earlier surgical procedures and treatments taken and obtained the policy by suppressing facts regarding earlier illness, whereas the complainant was saying before District Forum that necessary information was provided to the insurance company and when in the year 2003 he was suffering from some problem in his eye then he was examined by local Doctor and thereafter by Ophthalmologist of Medical College Raipur, who found that he was having pterygium in the left eye and cataract in right eye. Operation was suggested by the Doctor of Medical College Raipur, but he preferred to go to Shankara Netralaya Ghennai, where cataract was removed by performing operation under phaco procedure and pterygium was also excised. He was required to spent Rs. 44,276/ - on his treatment after admission in Shankara Netralaya Chennai and therefore preferred a claim before the insurance company for reimbursement of expenditure, which has been unnecessarily repudiated by the insurance company and thus, it committed deficiency in service, so the complaint was filed.
(3.) THE insurance company reiterated its defence before the District Forum that it is a case of concealment of material facts at the time of making proposal for medi -claim policy by the complainant/a'ppellant and therefore the claim was not payable. It has also been denied by the insurance company that a medi -claim policy was earlier issued by New India Assurance Co. Ltd. and the complainant switched over from that Company and cover was obtained from the respondent Company. It was a new insurance cover, in which material facts were suppressed, so no claim was payable. Earlier also the District Forum had dismissed the complaint, then appeal was preferred before this Commission, as appeal No. 607/06, which was decided on 10.07.08 and the case was remanded back to the District Forum for consideration of expert opinion produced before this Commission along with application under order 41 rule 27 of CPC and some other documents, that is how the District Forum again considered case and again dismissed it.;