DISTRICT CONSUMER DISPUTES REDRESSAL FORUM
SOUTH 24 – PARGANAS , AMANTRAN BAZAR, BARUIPUR, KOLKATA-700 0144
C.C. CASE NO. _128_ OF ___2015_
DATE OF FILING : 30.3.2015 DATE OF PASSING JUDGEMENT: 30/06/2017
Present : President : Udayan Mukhopadhyay
Member(s) : Subrata Sarker & Jhunu Prasad
COMPLAINANT : Prasenjit Halder, son of late Ranjit Halder of 104/4/10, Satyen Roy Road, P.S Behala, Kolkata -34.
-VERSUS -
O.P/O.Ps : 1. National Insurance Co. Ltd. at 3, Middleton Street, Kolkata-71.
2. Divisional Manager, National Insurance Company Ltd. Dviision-XIV, 7, Council House Street, 4th Floor, Kolkata – 1.
3. Medi Assist India TPA Ltd. 53A, Rafi Ahemed Kidwai Road, 1st Floor, Opp. Hotel Gulshan, Kolkata – 16.
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J U D G E M E N T
Udayan Mukhopadhyay, President
This is an application under section 12 of the C.P Act, 1986 filed by the complainant on the ground that O.P-1 is a reputed Insurance Company dealing with various policies, schemes and medical policies. O.P-2 is the Branch office of O.P-1. O.P-3 is the TPA in respect of the mediclaim insurance out of which complainant vests his claim. It has further stated that complainant had entered into a contract of insurance with the O.P-1 through O.P-2 sometimes since 2010 and the policy of mediclaim was a flo0ater Health Insurance Policy for a sum assured of Rs.1,25,000/- and thereafter each year the policy was renewed along with more amount of sum assured. It has further claimed that in the period of 2014-15 the said policy being policy no. 1030001000009 the sum assured was for the sum of Rs.3 lacs fo the complainant, Rs. 3 lacs for his wife and Rs.2,18,750/- for their minor daughter. The complainant has claimed that insurance policy renewed up to the date including the current year 2015-16 since 2.2.2010 .
It has alleged that minor daughter of the complainant Piuli Halder was suffering from Pass Discharge and had been treated on several occasions since January, 2014. Thereafter when several modes of treatment failed ultimately at the advice of Dr. Apurba Ghosh visited Surgeon Dr. P.P. Gupta and was admitted at Sri Aurobindo Seva Kendra at Gariahat Road and surgery was performed there and thereafter she was discharged on 28.3.2014. The complainant had incurred total hospitalization charges and treatment cost of Rs.51,923/- and he submitted claim Form with the O.P-3 for reimbursement of the said amount for the claim. It has claimed that complainant visited several times at the office of O.P-3 and enquire about the status of the claim but always O.P-3 assured that shortly the matter will be settled and it will be intimated to the complainant. Thereafter complainant again visited the office of theO.P-1 who are sitting tight over the matter. It has claimed that complainant is a legal practitioner and inspite of his regular busy schedule he kept in touch with the O.Ps but no fruitful result comes out. It has strongly claimed that the Insurance Proposal was accepted after all medical examination towards his daughter. So, question of pre-existing disease does not arise. Moreover, in the policy it has mentioned that after 48 months of insurance of the first policy and thereby extension of the same was also covered pre-existing disease in case of claim. Thus non-settling the dues is a deficiency of service and unfair trade practice and hence complainant has filed this case to direct the O.Ps to release Rs.51,923/- towards the mediclaim expenses and direct to pay compensation only Rs.10,000/- , litigation cost Rs.10,000/- etc.
The O.P nos. 1 and 2 are contesting the case by filing written statement and have denied all the allegations and claimed that this case is not maintainable. It is the positive case of the answering O.P nos. 1 and 2 that complainant has misconception about exclusion clause no.4 attached with the policy schedule. It has claimed that the policy is binding upon the parties. The exclusion clause no.4 clearly states that the company shall not be liable to make any payment under the policy in respect of any expenses incurred by any person in connection with or in respect of: The exclusion clause no.4 starting from exclusion clause no.4.1 to 4.31 describing various exclusions of diseased that are not falling with the scope of the policy and the policy wordings are duly approved by the IRDA the Regulator of Insrucne. It has claimed that Discharge Certificate dated 18.3.2014 diagnosed “Infected Umbilical Cystic Swelling” which was confirmed by USG Report dated 8.3.2014 . It has claimed that Organised Granuloma deep to Umbilicus noted and Umbilical Granuloma is a congenital disorder i.e exclusion clause no.4.5 falling under congenital diseased are permanently excluded and are not payable in terms of the policy. Hence, the claim is not payable and stands repudiated and complainant received the repudiation letter and thus deficiency of servicer does not arise and prays for dismissal of the case . The O.Ps also pray for imposing a fine of Rs.10,000/- for filing a frivolous and vexatious complaint in terms of the C.P Act, 1986.
The case is running in exparte against O.P-3.
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
Admittedly complainant and his family members including minor daughter had a policy running from the year 2010 and which is renewed year after years and at the time of treatment of complainant’s daughter the policy was valid.
Now question is whether the disease is congenital external disease or defects or anomaly or not.
We have turned our eyes on the policy itself and we find that Internal congenital anomaly means congenital anomaly which is not in the visible and accessible parts of the body and External congenital anomaly means congenital anomaly which is in the visible and accessible parts of the body in terms of the policy. Again in terms of clause no.4.5 it has mentioned in the exclusion clause of pre-existing disease that general debility, run down condition or rest cure, congenital external disease or defects or anomaly.
Thus congenital external disease or defects or anomaly falls under clause 4.1 pre-existing diseases, wherein it has been specifically mentioned in clause 4.1 pre-existing disease that all pre-existing disease when the cover incepts for the first time until 48 months of continuous coverage has elapsed. Herein, admittedly 48 months already over since the policy is running since 2.2.2010.
Now the question is as per claim of the O.P the infected umbilical cystic swelling is false. Congenital disorder cannot be proved by any medical documents or any medical authors observation. On the other hand discharge summary clearly stated that the patient was admitted with the pus discharge from umbilicus for last 20 days , also complaints of fever. So, we are not in the same view with the Insurance company to repudiate the claim, particularly when the claim amount is very meager one in comparison with the sum assured . Apart from that when there is anomaly and complication of the medical opinion and when there is no specific medical opinion, how it was repudiated This is not the just decision of repudiating the claim by the Insurance company like O.P-1, particularly when the complainant is paying premium since first part of 2010 and claiming only a meager amount after five years.
It is true that USG report speaks “Organised granuloma – deep to umbilicus noted”. But there is no nexus with the final diagnosis i.e umbilical cystic swelling. Swelling can be easily seen. So, there is no nexus with the congenital disorder as well as the infected umbilical cystic swelling . This disease is not fall under clause 4.5 of the policy. Moreover, a five years baby is suffering from some disease and her pain and suffering should not be thrown away by repudiating the claim amount of Rs.51,923/-. The reputed Insurance Company i.e O.P-1 should re-think the matter for the name and fame of their Institution as a leading Insurance Company.
With that observation it is ,
Ordered
That the complaint case is allowed on contest against O.P nos. 1 and 2 and dismissed in exparte against O.P-3.
The O.P nos. 1 and 2 are hereby directed jointly and/or severally to release the claim amount of Rs.51,923/- along with compensation to the tune of Rs.5000/- and litigation cost of Rs.3000/- to the complainant within 30 days from the date of this order, failing which, the interest will carry @9% p.a till its realization.
The complainant is at liberty to execute the order through this bench after the stipulated period is over.
Let a plain copy of this order be served upon the complainant free of cost and one copy be sent to the O.Ps through speed post.
Member Member President
Dictated and corrected by me
President
The judgment in separate sheet is ready and is delivered in open Forum. As it is ,
Ordered
That the complaint case is allowed on contest against O.P nos. 1 and 2 and dismissed in exparte against O.P-3.
The O.P nos. 1 and 2 are hereby directed jointly and/or severally to release the claim amount of Rs.51,923/- along with compensation to the tune of Rs.5000/- and litigation cost of Rs.3000/- to the complainant within 30 days from the date of this order, failing which, the interest will carry @9% p.a till its realization.
The complainant is at liberty to execute the order through this bench after the stipulated period is over.
Let a plain copy of this order be served upon the complainant free of cost and one copy be sent to the O.Ps through speed post.
Member Member President
