ORDER

A. K. Tiwari, Presiding Member—This is an appeal filed by the complainant/appellant against the order dated 23.03.2019 passed by the District Consumer Disputes Redressal Commission, Damoh (for short ‘District Commission’) in C.C.No.03/2016 whereby the complaint filed by him has been dismissed.

2. The facts of the case in short are that the complainant had obtained a mediclaim (Family Floater Plan) policy no. 0200606457 for a period from 30.05.2015 to 29.03.2016 covering the risk of himself and his wife after paying premium of Rs.8,948/-. After taking the policy his wife Seema Jain felt pain in left side of chest, upper lips and in tooths and mouth. Thereafter on 16.10.2015 she got admitted in Sir H. N. Reliance Foundation Hospital, Mumbai, where she underwent neurosurgery on 17.10.2015 and discharged on 20.10.2015. He incurred Rs.1,33,945/- in treatment expenses. On 10.11.2015 he made a claim through opposite party no.4 bank to the opposite party no.1 to 3 insurance company. On 10.12.2015, the insurance company send him a reminder asking case sheet, bills vouchers, photographs, cancelled cheque and discharge summary etc. Then on 15.12.2015, he had send all the documents to the insurance company even then the insurance company by sending reminders dated 23.12.2015 and 31.12.2015 asking the relevant documents. Ultimately, the insurance company rejected the insurance claim on 27.02.2016. Again on 04.03.2016 documents were sent but no action was taken. Aggrieved complainant therefore filed a complaint alleging deficiency in service on part of the insurance company and TPA, before the District Commission seeking claim of medical expenses incurred to the tune of Rs.1,33,945/-, compensation and costs.

3. The opposite party no.1-TPA remained absent before the District Commission and was proceeded ex-parte.

4. The opposite party no.2 & 3-insurance company resisting the complaint raised objection that from the documents submitted by the insured-Seema Jain it came to the knowledge that the insured Seema Jain was suffering from hypertension since September-2014 i.e before the taking the policy on 30.03.2015 which she did not disclose in the column of medical history in the proposal form to obtain the policy. Therefore the insurance claim was rejected as the insured suppressed the material information regarding her health. It is submitted that the insured did not file the complaint and therefore, the complaint is not maintainable. It is further submitted that despite repeated reminders dated 10.12.2015, 21.12.2015, 23.12.2015, 31.12.2015 and 11.01.2016 the complainant did not supply the requisite documents as sought for. On 12.01.2016 show cause letter was also sent. On this ground also the claim was repudiated as no claim. There has been no deficiency in service on part of the opposite party no.2 & 3 insurance company. It is thus prayed that the complaint be dismissed.

5. The opposite party no.4-bank resisted the complaint stating that they got their account holders insured with the insurance company and it is for the insurance to decide the claim and to pay the amount or not. The bank has no role. The opposite party no.4 did not commit any deficiency in service. It is therefore prayed that the complaint be dismissed.

6. Heard learned counsels for the parties and perused the record.

7. Learned counsel for the complainant/appellant reiterated the same facts as has been stated in the complaint that despite fulfilling all the formalities and submitting requisite documents, the insurance company committed deficiency in service in repudiating the claim. He further argued that the District Commission committed grave error in dismissing the complaint. He therefore prayed that the appeal be allowed and the complainant/appellant be granted compensation as claimed in the complaint.

8. Learned counsel for the opposite party no.2 & 3-insurance company argued that despite repeated reminders the complainant did not produce the requisite documents