West Bengal

South 24 Parganas

CC/10/2015

Dipta Sankar Prajapati - Complainant(s)

Versus

1 Branch Manager Star Health and Allied Insurance Company Ltd - Opp.Party(s)

Dipa Sen Maity

05 Feb 2016

ORDER

 

                                     DISTRICT CONSUMER DISPLUTES REDRESSAL FORUM

SOUTH 24 – PARGANAS ,

Amantran Bazar, Kulpi Road, Baruipur, Kolkata – 144.

C.C. CASE NO. __10___ OF ___2015____

DATE OF FILING : 8.1.2015_     DATE OF PASSING JUDGEMENT:__05.02.2016____

Present                                :   President       :   Udayan Mukhopadhyay

                                                    Member(s)    :   Sharmi Basu  &  Subrata Sarker

COMPLAINANT                 :  Dipta Sankar prajapati, Block-2, Gouri Apartment,

                                                   Boalia, Garia, Kolkata – 84.

• VERSUS  -

 

O.P/O.Ps                                             :  1. Branch Manager, Star Health and Allied Insurance Co. Ltd.

                                                   Branch office-Behala, 2^nd Floor, 738/2, Diamond Harbour Road,

                                                   P.S. Behala, Kolkata – 8.

                                                                   2.     Branch Manager, Star Health and Allied Insurance Co. Ltd.

New Tank Street, valluvar Kottam High Road, Nungambakkam, Chennai – 600034, P.S. Nungambakkam.

_____________________________________________________________________________________

                                                                                J  U  D  G  E  M  E  N  T

Sri Udayan Mukhopadhyay, President

                This complaint is filed under section 12 of the C.P Act, 1986 on the ground that being a Senior Citizen complainant has obtained one Senior Citizen Red Carpet Insurance Policy from the O.P on 16.7.2012 being Policy no. P/191117/01/2013/001322  for the period from 16.7.2012 to 15.7.2013 after taking premium of Rs.5000/-. It has further submitted that on 5.10.2012 while complainant was leaving at his daughter’s residence at Angul, Orissa, he fell ill with acute diarrhea and he was immediately brought to Dr. Prarida, a registered medical practitioner of the locality at Amlapada, Angul, Orissa, who examined the physical condition of the patient and treated him for his acute food poisoning and gastriotis. Since the condition of the patient was gradually being deteriorating ,he was brought and admitted to Chandan Nursing Home, Simplipada, Angul, on the same day. But the condition of the complainant did not improve till 7.10.2012 and he was admitted to ARogya Maternity and Nursing Home for his treatment  as per annexure 2,3 and 4 of the complaint. It has further stated that soon after his admission and as per terms and conditions of the policy pre authorization request for cashless facility was submitted by the complainant for an approximate treatment expense of Rs.31,000/- vide claim intimation no.CLI/2013/191117/0105953. But the aforesaid claim for cashless facility was summarily rejected on a ground that complainant was suffering from high HbA1C before obtaining the insurance policy. It has further  stated that complainant also doctor’s opinion regarding his blood sugar level to the O.P Insurance Company which was averred for the first time by the complainant but O.P wanted to get CT scan report also. But thereafter cashless facility was turned down on 14.10.2012 on the ground that onset of disease likely to be prior to taking of policy as per Annexure 5,6,7,8 and 9 . Thereafter complainant was discharged on 18.10.2012 with a diagnosis with “Pituitary Macrodenoma with Hypoadrenalism and Hyponutremia, Visual Field Defects , HTN”. But the complainant lodged claim for reimbursement of Rs.68,460/- vide claim petition dated 22.11.2012 . But the said claim was repudiated on the same baseless ground of pre-existing disease as per Annexure 9a, 11 and 12). It has further stated that complainant thereafter went to C.M.C Vellore , Tamilnadu, to obtain better treatment and was admitted there on 25.2.2013 ,where it was diagnosed that he was suffering from non-functioning of pituitary Macrodenoma with Apoplexy Hardy’s Grade-B. It has been further stated that while the O.P was underwent treatment the Insurance Co. issued a letter dated 30.1.2013 to his daughter and thereby communicated that the said policy had been cancelled and a DD of Rs. 2027/- stated to be prorate of the premium was remitted to the complainant which is annexure 13,14b of the complaint. It has been claimed by the complainant that he had no knowledge of the said disease till the reports of the doctors of Calcutta Nursing Home and CMC , Vellor came to his hand and ,therefore, complainant had no scope of concealment of the disease as it was beyond his constructive knowledge. He has taken the insurance policy with the O.Ps after his retirement only to indemnify the medical cost in his old age. Hence this case for deficiency in service and unfair trade practice and pray for claim of Rs.1 lac along with interest and also Rs.50,000/- more for compensation and cost of litigation.

                The O.Ps are also contesting the case by filing written version and has denied all the allegations leveled against them. It is the case of the O.P that during subsistence of the subject policy the O.P received pre authorization request from Arogya Maternity and Nursing Home, Kolkata art the instance of the complainant and having scrutinized the treatment records, the medical team of this O.P observed that the present ailment is symptomatic prior to the inception of the subject policy and hence as per terms and conditions of the subject policy, cashless authorization was denied and also the same was communicated to the treating hospital and the complainant by letter dated 14.10.202. It is the further case of the O.P that on careful perusal of the medical records of the complainant to treatment at ARogya Maternity Nursing Home , O.P found that complainant was treated for Pituitary Macrodenoma with Hypoadrenalism and Hyponatraemia. On further scrutiny it was found on perusal of MRI report that there is lobulated soil tissue of size 26 x 18 x 30 mms of mass and it is also fact that said disease is a slow growing tumour and the growth of the pituitary tumour of the complainant was extensive which clearly indicates that the subject ailment has been longstanding which was also to the knowledge of the complainant and that the said disease/symptom cannot occur within two months from the date of inception of policy and based on such rationality and medical finding. So, this disease is a pre existing disease. Moreover, complainant was suffering from thyroid disease which he has not disclosed at the inception of the subject policy. So, condition no.7 of the subject policy is attracted in this case. It has further stated that after receiving notice from the Ld. Forum they again in consultation with the medical team reviewed the settlement of claim and it is as per exclusion no.5 of the subject policy ,50% of each and every claim arising out of the said all pre-existing diseases as defined and 30% in case of rest of other claims have to be borne by the complainant and thus for 1^st admission of total bill amounting Rs.74,810/- this O.P settled the total amount at Rs.48,444/- by deducting Rs.28,366/- and has allowed further sum of Rs.11,566/- against the total bill of Rs.1,11,527/- for admission at Vellor which is successive 2^nd time admission in the hospital within the same insurance period within the purview and scope of the subject policy. The O.P has clarified the reasons for deduction as per IRDA Guidelines dated 22.2.2013 . Accordingly, O.P prays that complainant may be directed to accept the rationally settled amount of sum for medical expenses disbursement within the four corners of the subject policy and further prayers of the complainant may be dismissed being irrational and unscientific.

                Points for decision in this case is whether there is any deficiency in service or unfair trade practice on the part of the O.Ps or not.

                                                                                Decision with reasons

We are aware that Senior Citizen Red Carpet Insurance Policy was obtained by the complainant for the period 16.7.2012 to midnight of 15.7.2013 and the sum assured is Rs.1 lac.  Complainant treated at Arogya Maternity and Nursing Home and from Claim Form as well as discharge bill it appears that Rs.698, 460/- was the expenditure towards the ailment of the complainant and complainant after admitting there sent one intimation for cashless benefit which was repudiated by the O.P on the ground that at the time of taking  policy from 16.7.2012 complainant did not disclose the above mentioned medical ailment in the proposal form. So, the same is misrepresentation and non-disclosure of material facts ,for which the cashless benefit was turned down and the claim was repudiated also. The O.P not only repudiated the claim but they have sent a letter dated 30.1.2013 to the complainant informing that policy was cancelled on prorate basis and for the remaining period the policy the premium is refunded. The ground is non-disclosure of material facts about the pre-existing disease.

                Now the question is whether the ailment of the complainant is pre-existing disease or not.

                It is the case of the complainant which we have narrated at the time of discussing the case of the complainant that initially complainant was suffering from acute diarrhea and examined by a registered Practitioner at Orissa when condition was gradually deteriorating and he was brought to the Arogya Maternity Nursing Home for his treatment. Thus, we find that complainant experienced regarding his health condition soon after admitted in the hospital and thereafter further better treatment at C.M.C Vellore and prior to that she was not admitted in any hospital for the treatment as claimed by the O.P as a pre-existing disease. Moreover, O.P did not file any report of his medical team regarding pre-existing disease of the complainant. Apart  from that  if we turn our eyes on the discharge summary of Christian Medical College, Vellore, then we find that the treating doctor of C.M.C Vellore has observed that complainant was a known hypertensive and hypothyroid patient since October, 2012 and was on regular medication . There was no other comorbid illnesses. Thus, we find that complainant was suffering from hypertensive and hypothyroid patient since October, 2012  and policy was taken on 16.7.2012 which is admitted fact. So, can it be said that it is a pre-existing disease, until and unless O.P is able to prove that the complainant was admitted in any Nursing home or hospital for the said disease prior to taking the policy which is on or before 16.7.2012.  ANSWER IS NEGATIVE.  So, when the complainant/consumer suddenly suffered illness and after thorough check up the ailment was detected , the same is not a pre-existing disease. It is really unfortunate that when the complainant is suffering for better treatment the O.P cancelled the policy inspite of accepting the premium and refunded the premium on prorate basis. This is also a glaring example of unfair trade practice. It should not be the motive and attitude of any Insurance Company that when they observed that they are bound to pay the insurance claim, they will cancel the policy insptie of accepting the premium. It should be mentioned here that period of policy was 16.7.2012 to midnight of15.7.2013. Thus the O.P is duty beyond to meet all expenses ,off course, not above the sum assured within the period of the said policy ,particularly when O.P has failed to prove miserably regarding the pre-existing disease and suppression of material facts as claimed in the repudiation letter. Moreover, it is the landmark judgment of Hon’ble National Commission reported in III (2014) at page ,wherein Hon’ble National Commission clearly suggests that in the said reported case O.P Insurance Company did not produce any evidence to prove that which medication and for how long the complainant was taking for diabetes /hyper tension, thus O.P cannot apply hard and fast rule to presume that complainant was suffering for long duration i.e. before taking the policy . it has been further observed by the Hon’ble National Commission that “It is known that many times healthy persons are unaware of such silent ailment of diabetes and hyper tension which comes to their knowledge for the first time during health check up or anything emergency situation. So, the argument of the Insurance Company is not convincing and observed that  no doubt, the medical literature states that hypertension and diabetes are risk factors for  Coronary Artery Disease, but the O.P failed to prove that those diseases are pre-existing in this case. It was just a hypothetical presumption  of the O.P to repudiate the claim of the complainant”.

                 Here in the instant case we also find that there is no evidence produced by the O.P to claim that complainant is suffering from the said disease and it has come to our knowledge of the complainant after admitting him in the Nursing Home and C.M.C Vellore. So, this hypothetical presumption of the O.P to repudiate the claim is not justified. Thus relying the judgement of the Hon’ble National Commission and relying the circumstances by which it was detected ,we are constrained to hold that the disease of the complainant is not a pre-existing disease. Moreover,  we failed to understand that Doctors of Arogya Maternity Nursing Home has given one Certificate on 10.10.2012 that the complainant was neither diabetic in the past nor is in the present and HbAIC 6.7 never be proof of DM . It has further observed that patient was vomiting, confusion and restlessness. Thus we find that insptie3 of certificate issued by the treating doctor of Arogya Maternity Nursing Home O.P ha chosen to take the shelter of unfair trade practice and that is why repudiated the claim unnecessarily and it is not the last. They have cancelled the policy during the period of the policy which is another glaring example of unfair trade practice and deficiency in service.

                 Thus complainant has been able to prove his case and after cancellation complainant was unable to raise further claim which he paid to the CMC Vellore amounting to Rs.1,11,527.64p. Thus ,considering the total circumstances complainant cannot get more amount that sum assured i.e. complainant will get only Rs. 1 lac towards her ailment. It should be mentioned here that after the period of 15.7.2013 which has already been expired ,right now, O.P is not duty bound to extend the existing policy. But during the period of existing the policy O.P is duty bound to meet the medical expenses within the amount of sum assured, particularly when the O.P has failed to prove the pre-existing disease as claimed by producing any single documentary evidence . Mere, assertion is not suffice to say that complainant’s disease was a pre-existing disease and if we accept the contents of the O.P then the dark days of the complainant will be spread out and thereby this type of Insurance company will get more money from the poor complainants/consumer with the assurance to give medical assistance as and when required.

                With that observation, it is

                                                                                                Ordered

That the application under section 12 of the C.P Act is allowed on contest against the O.ps with cost.

The O.Ps are directed to pay Rs.1 lac towards the medical treatment of the complainant within 45 days from the date of this order ,failing which, interest will carry @9% p.a from the date of filing this case till its realization.

The O.Ps are further directed to pay a compensation for non settling the medical  expenditure and thereby ailing complainant did not get any peace by expending more than the sum assured for compensation is just and proper amounting to Rs.25000/- and litigation cost is Rs.5000/- which will be paid by the O.Ps jointly and/or severally to the complainant within 45 days from the dale of this order.

It may be mentioned here that if the awarded amount as directed by this Forum be not paid within stipulated period then further interest will carry @15% p.a on the total sum from the date of this order till its realization and in that event complainant is at liberty to get the order executed through this Forum.

Let a plain copy of the judgement be supplied to the complainant free of cost  and a plain copy be sent to the Opposite parties  at their address as mentioned in the Cause title through this Forum free of cost.  Office to do the needful.

Member                                                              Member                                                              President

 

Dictated and corrected by me

 

                                President

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The judgement in separate sheet is ready and is delivered in open Forum. As it is ,

Ordered

That the application under section 12 of the C.P Act is allowed on contest against the O.ps with cost.

The O.Ps are directed to pay Rs.1 lac towards the medical treatment of the complainant within 45 days from the date of this order ,failing which, interest will carry @9% p.a from the date of filing this case till its realization.

The O.Ps are further directed to pay a compensation for non settling the medical  expenditure and thereby ailing complainant did not get any peace by expending more than the sum assured for compensation is just and proper amounting to Rs.25000/- and litigation cost is Rs.5000/- which will be paid by the O.Ps jointly and/or severally to the complainant within 45 days from the dale of this order.

It may be mentioned here that if the awarded amount as directed by this Forum be not paid within stipulated period then further interest will carry @15% p.a on the total sum from the date of this order till its realization and in that event complainant is at liberty to get the order executed through this Forum.

Let a plain copy of the judgement be supplied to the complainant free of cost  and a plain copy be sent to the Opposite parties  at their address as mentioned in the Cause title through this Forum free of cost.  Office to do the needful.

Member                                                              Member                                                              President