Date of filing :16.5.2017

Judgment : Dt.13.3.2018

Mrs. Balaka Chatterjee, Member

            This petition of complaint is filed under section 12 of   C.P.Act, 1986 by Himangsu Sekhar Barman alleging deficiency in service on the part of the opposite parties (Referred as OP hereinafter) namely (1) Apollo Munich Health Insurance Company Ltd. and (2) Canara Bank as Proforma OP.

            Case of the Complainant in brief is that he is a senior citizen of India and a retired employee of the OP No.2 Bank which is also the IRDA approved licensed Corporate agent of the OP No.1 Health Insurance Service Provider. The Complainant has stated that he had entered into a contract Insurance (Health) for the first time on 16^th September, 2015 for a sum assured of Rs.5,00,000/- and the  same was subsequently renewed on 16^th September, 2016 upto 15^th September, 2017 (inclusive both days) in respect of the Complainant and his wife Mrs. Saraju Barman and, accordingly, premiums were duly paid by the Complainant. It is stated that in mid October, 2016, Mrs. Saraju Barman was suffering from low hemoglobin with blackish stool and due to the same was admitted to Fortis Hospital Limited 730, Anandapur, E. M. By Pass on 25.10.2016 under the treatment of Dr. Debashish Dutta of Gastroenterology Department who administered conservative treatment with medicine along with three units of blood and several clinical tests including colonoscopy. The patient was discharged on 28.10.2016 from the said hospital although the reports of C.T. Scan and Biopsy report were yet to be obtained. The Complainant incurred an expenditure of Rs.97,932/- and, accordingly, submitted his claim in respect of another health Insurance Policy issued by United India Insurance Company Ltd. and a sum of Rs.82,256/- was disbursed in favour of the Complainant. Subsequently, wife of the Complainant had undergone a further treatment in respect of which surgery was done as to left haemocolectory and Frozen Section Biopsy performed on 18.11.2016 and she was discharged o n 3.12.2016. The Complainant again incurred an expenditure of Rs.5,35,550/- and, therefore, filed his claim before United India Insurance Company Ltd. and an amount of Rs.4,00,000/- was approved for cashless treatment. The Complainant had to pay a sum of Rs.1,69,898/- and filed his claim for reimbursement of the said amount with the OP No.1 on 14.12.2016 with duly filled up claim form along with a covering letter. The Complainant has further stated that he received a letter on 23.01.2017 intimating rejection of his claim on the ground of details of Medical history of psychiatric illness was not revealed by the insured person which amounts to breach of good health declaration under sec.4(f) of said policy. The Complainant has stated that on the very next day i.e. 17.1.2017 he received another letter from the OP wherein it was reiterated that for the reasons above stated, the policy stood terminated with notice of 30 days for renewal. Subsequently, on 3.2.2017 the Complainant had written a letter in reply to the aforesaid letter wherein he specifically denied the alleged repudiation of claim ascertaining that the Insured person was diagnosed and treated for left haemecolectory which is unrelated to any anxiety related disorder and the said letter was acknowledged by the OP vide an e-mail dt.3.2.2017.Subsequently, the OP No.1 by an e-mail dt.11.2.2017 requested the Complainant for granting some time but ultimately by an e-mail dt.2.3.2017 expressed their inability to process the request which prompted the Complainant to send another e-mail to Sri Padmesh Nair, the Chief Grievance Officer of OP No.1, who in reply, by another e-mail dt.9.3.2017, and subsequently,  on 15.3.2017 requested the Complainant to allow a spell of time to reconsider the grievance but ultimately by another e-mail dt.22.3.2017, the OP No.1 reiterated their earlier decision along with several screen shots of earlier medical prescription of the wife of the Complainant. The Complainant further stated that since then his wife was admitted to Hospital on six occasions for chemotherapy for its different cycles and on every occasion he was covered by united India Insurance Company Ltd.

            The Complainant further stated that after institution of thiS case the OP No.1 deducted a sum of Rs.5,586/- from the S.B.A/C No.1861111013000 on 7.9.2017 being the premium amount and renewed the policy for the period 16.9.2017 to 15.9.2018.

 According to the Complaint, the OP No.1 has repudiated his claim without any valid reason which tantamounts to deficiency in service and prayed for direction upon OP No.1 to recall and/or rescind the termination of policy letter dt.17.1.2017, direction upon OP No.1 to pay Rs.1,69,898/-, to pay Rs.5,00,000/- towards compensation and Rs.1,00,000/- as litigation cost.

            The Opposite Parties contested the case and filed written version respectively. The OP Insurance Company Ltd. i.e. the OP No.1 in its written statement denied and disputed all material allegations stating inter alia, that instant Consumer Complaint is not sustainable for the reason since the word deficiency as defined under Section 2(1)(g) of C.P.Act, 1986 has no application with the facts and circumstances with the instant Consumer Complaint since the Complainant has lodged his claim for reimbursement of medical expense incurred by him in respect of his wife Mrs. Saraju Barman who had been admitted for the management of ADENO CARCINOMA LEFT COLON & underwent Exploratory Laperoctomy  with haemecolonectomy but had violated the terms and conditions of the Insurance Policy by not disclosing the material facts relating to her suffering from hypothyrocidism for past three years and her history of sufferings from psychiatric illness, anxiety, disturbed feeling since January 1999 to the OP Insurer at the time of signing of the proposal form. The OP No.1 has further stated that clause 4 of the enrolment form clearly mentioned that declaration and warranty on behalf of all persons to be insured regarding illness they were suffering from last five years except some minor ailment which are mentioned under the said clause in which psychiatric illness has not been included and as such non-disclosure of psychiatric illness suffered by the Insured patient was synonymous to suppression of material fact and as such the claim of the Complainant cannot be settled as well as likely to be rejected due to suppression of fact.

            The proforma OP No.2 Bank filed the written version stating inter alia that the OP No.2 Bank providing banking and related service to its customer and has acted only as an intermediatory at the time of selling of Health Insurance Policy and, therefore, that once any Insurance policy is availed by the Insured person from the Insurance Company the OP No.2 Bank has no connection with the same.

            The Complainant and the OPs adduced evidence followed by cross examination in the form of questionnaire and reply thereto.

            Ld. Advocate on behalf of the Complainant stated that the OP No.1 intentionally harassing the Complainant by repudiating the claim.

            Ld. Advocate on behalf of OP No.1 submitted that the Complainant did not provide medical history of the insured at the time of inception of the policy.

            Points for determination

1. Whether there is deficiency in providing service on the part of the OP?
2. Whether the Complainant is entitled to the relief as prayed for?

Decision with reasons

Both points are taken up together for discussion and decision.

            Admittedly, the Complainant obtained a policy in respect of him along with his wife issued by the OP No.1 through the OP No.2. To sum up, the Complainant stated that his wife who was diagnosed suffering from carcinoma in colon received treatment from Hospitals approved by the OP insurer. The Complainant had to send a certain amount for the said treatment and, accordingly, filed his claim for reimbursement of an amount of Rs.1,69,898/- with the OP No.1 Insurer but the same after exchange of correspondence on several occasions was rejected on the ground of suppression of material fact since the insurer found that the insured patient had been suffering from as well as under medication for psychiatric illness since 1999 whereas she along with her spouse (the Complainant) obtained Health Insurance Policy in 2015 suppressing the fact of said illness.

            In respect of an Insurance Policy, the Insurer indemnifies the Insured from the peril likely to occur against receiving premium from the Insured. In respect of a Health Insurance Policy, the Insurer indemnifies the Insured in case of diseases to be suffered by the Insured. As such, it is necessary for the Insurer to know that whether the prospective Insured has already been suffered from any pre-existing diseases so that the Insurer may calculate the risk of suffering from the future diseases by the prospective Insurer and as such that the Insurer may decide to which extent it can indemnify the insured.

            In the instant case, the ground of rejection of the claim filed by the Complainant for reimbursement of the expenses incurred by him for treatment of his spouse (The Insured patient), for ADENO CARCINOMA of Colon is for non-disclosure of the pre-existing psychiatric illness suffered by her since 1999. The Insurer did not utter a single sentence within four corners of written statement adduced by OP Insurer not even in the affidavit in evidence that suffering from psychiatric illness affects colon of the patient and as such ADENO CARCINOMA of Colon likely to on set. Therefore, it is evident that OP Insurer made the inadvertence committed on the part of the Complainant as ground for rejection to indemnify him from the peril suffered by him. This is absolutely contrary to the principle of equity.

            In such view of the matter, we are of opinion that the OP Insurer was not justifiable in rejection of the claim submitted by the Complainant.

            The Complainant has prayed for disbursement of Rs.1,69,898/- towards claim amount that we are not in position to direct the OP insurer to disburse the said amount since the disbursable amount is determined by recommendation of the third party administrator. The Complainant has prayed for direction for payment of Rs.5,00,000/- by the OP towards compensation and Rs.1,00,000/- as cost of litigation. In this regard, we think it will be just and proper if the Complainant gets a consolidated amount of Rs.2,00,000/- towards disbursable amount in respect of the Insurance claim and compensation and cost of litigation.

            Point Nos.1 & 2 decided accordingly.

            In the result, the Consumer Complaint succeeds in part.

            Hence,

ordered

            That CC/271/2017 is allowed in part on contest with cost.

            The OP No.1 is directed to pay Rs.2,00,000/- to the Complainant within one month from the date of this order.