IMPORTANT POINT
Mediclaim cannot be allowed on the basis of void authorization letters.

Dr. S.M. Kantikar, Member—This revision petition has been filed under Section 21(b) of the Consumer Protection Act, 1986 against the order dated 28.02.2011 passed in appeal No. 1273 of 2006 by Rajasthan State Consumer Disputes Redressal Commission (in short, ‘the State Commission’) whereby the appeal of the complainant was dismissed and the order of the District Forum was upheld.

2. Brief facts of the case are that the complainant Narendra Lal Jain/petitioner had purchased a medi-claim policy (good health policy) from the National Insurance Company – Opposite Party for himself and his wife for the period commencing from 01.02.2004 to 31.01.2005 for a sum of Rs.2,50,000/-. It was continuously renewed without any brake. The policy was issued after getting medical examination of the petitioner and his wife. During subsistence of the policy, the petitioner fell ill and took treatment at Bombay Hospital. After recovery from the illness, he submitted his claim to the Opposite Party. While undergoing the treatment for fever, few tests revealed first time that he was suffering from AIDS and prior to that, he was not aware or was detected for the same. The claim of the complainant was repudiated vide letter dated 15.07.2004 under exclusion clause 4.9. The complainant submitted that his treatment carried out at Bombay Hospital was for the disease Tuberculosis (T.B.) and no treatment for another disease was carried out. Previously, the Opposite Party issued authorization letters to the hospital.

3. Aggrieved by the repudiation, the complainant filed complaint before the District Consumer Disputes Redressal Forum II, Jaipur (in short, ‘the District Forum’) and prayed for compensation of Rs. 2 Lacs and Rs.11,000/- towards costs.

4. The Opposite Party resisted the complaint. The Opposite Party in its written statement submitted that the complainant was admitted in Bombay Hospital on 20.04.2004 and the test results revealed AIDS and T.B. The complainant without disclosing about the disease got authorization letters issued for Rs.1,85,000/-. Therefore, the authorization letters issued on wrong facts were null and void. As per the exclusion clause 4.9, the complainant was not entitled to get any claim, hence, it was repudiated.

5. The District Forum after going through the evidence and medical record, dismissed the complaint holding that the authorization letters issued earlier were null and void. Being aggrieved by the order of the District Forum, the complainant filed an appeal before the State Consumer Disputes Redressal Commission, Rajasthan. It was also dismissed. Hence, the complainant filed this revision petition.

6. We have heard the learned counsel for both the parties. The learned counsel for the complainant vehemently argued that the Opposite Party had issued authorization letters and later on rejected the claim. The complainant incurred Rs.2,49,973/- as hospitalization expenses. Arguments were made on behalf of the Opposite Party that complainant concealed his disease before taking authorization and it was fraudulently obtained. Hence, the repudiation was justified.

7. We have considered the arguments of both the parties and perused the relevant medical record on the file, the policy conditions and exclusion clause. As per the exclusion clause 4.9, on 20.04.2004, the complainant was diagnosed Positive for HIV-I and HIV-II. He was also suffering from T.B. Regarding the authorization letters, issued by the hospital on representation of the complaint without disclosing the disease, the complainant had disclosed only fever, but not disclosed about the test report of HIV which was positive. It is transpired from the record that first authorization dated 26.04.2004 was issued on the date of discharge of the complainant and the complainant did not furnish complete information to the opposite party. The exclusion clause 4.9 of the policy clearly states as under:

“4.9 All expenses arising out of any condition directly or indirectly ca