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FACTS

2. The factual matrix leading to the case of the complainant is that the complainant being allured by the advertisement of the oP insurer has purchased the Medi-claim policy for sum assured of Rs.10.00 lacs u.nder the plan 'senior citizens Red carpet Health lnsurance policy' vide policy No. Pl7oooo2lo1,/2o18l000106. The Policy was valid from 5.4.2afl to 4.4.2018. lt is alleged inter alia that the complainant while filling up of the proposal form. has admitted to have suffered from diabetic and hypertension. However, ofi 10.1.201g complainant having suffered from high fever got him admitted to the Apolto Hospital and after necessary treatment discharged on 18.1.2018. During hospitalisation, he has informed about his hospitalisation to the OP - insurer for cashless facitities. But the insurer raised the issue with regard to two more diseases i.e. Rheumatoid Arthritis and copD which he has not disclosed during filling up of the proposal form. Therefore, the op refused to provide cashless facilities but asked to submit documents to settle the medical expenses on reimbursement basis.

4- OP filed written version admitting about purchase of i t Senior Citizens Red Carpet Health lnsurance Policy from them by .1 rr , . I . the complainant. lt is also admitted that the comptainant was i i )rn /v\ -, :, hospitalised on 10.1.2018 in Apollo Hospital and informed the oP for cashless facilities. op further averred that the complainant has not disclosed about his previous hospitalisation while suffering from copD with sero positive rheumatoid arthritis for which they denied the cashless facilities but at the same time, asked the complainant to claim the reimbursement of the medical expenses. After receiving the application the op enquired into the matter and found not only complainant has become adamant to produce the hospitalisation records of sAAoL Heart centre but also failed to produce his cr rest report dated 27.9.201,6 undertaken in opD and his USG report dated 25.9.2017 held in AHC. As the complainant did not comply the letter of the oP dated rq.zt.zotg, 1.3.201g and 16.3.201g, they found violation of policy condition no.4.4 of the policy and accordingly, repudiated the claim on 20.3.201g. lt is the case of the oP that they have got information that the complainant was hospitalised for sero positive Rheumatoid Arthritis and copD but unfortunately, that was not included in the proposal form of policy by complainant, the reasons of same is,best known to the complainant. since the additional information was not received, there was no other way than to repudiate the claim. Therefore, there is no deficiency in service and unfair trade practice on the part of the oP. As such, the op prayed to dismiss the complaint as case of complaint is not covered by condition no.4.4 of the policy. on the other hand,,the insurer is not riabre to pay any amount to the complainant.

i) Patient has beeri admitted in saaol Heart centre on 21.5.2016. Kindly submit its complete hospitalisation records with reports.

ii) Patient has taken CT Chest on 21.9.2016 in OpD and USG on 25.9.2017 in AHC. Kindly submit its consultation paper and admission records.

iii) As per submitted indoor case papers patient is a known case of sero positive Rheumatoid Arthritis. Kindly get a letter from treating doctor regarding the duration of RA, DCMP and copD and submit first and all past consultations since diagnosis of RA an copD with RA Factor report when RA was first diagnosed, past chest X-ray report and treatment taken for teh same.

8. The aforesaid reply clearly shows that he was neither treated nor hospitalised for rheumatoid arthritis because he was never suffering from such disease. Further, he has made it clear in the said reply that he had been to sAAoL Heart centre for therapy but not for any treatment of disease. He submitted that he has already submitted all the documents such as scan report, X-ray and discharge report but no previous history of copD was there. The reply of the complainant is very clear that he was neither suffering from rheumatoid arthritis nor copD. Rather being disgusted with the conduct of the op, he requested to settle the claim as soon as possible.