IN THE COURT OF THE PRESIDENT DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,KEONJHAR
CONSUMER COMPLAINT CASE NO. 11 of 2018
Anima Madhuri Dutta, aged about 44 years
W/O-Rajat kumar Dutta, Qr No E/1 Flat type
OSME Colony Mining Road, Po-Keonjhargarh,
P.s-Town, Dist-Keonjhar,……………………….……………………..……………………....…..… Complainant
Versus
1.Ashish Mehrotra
Managing Director and chief Executive officer
Max Bupa Health Insurance Co Ltd
B-1/1-2 Mohan cooperative
Industrial Estate,Mathura road
New Delhi-10044………………….……………………………………………………..……………………..Opp.Parties
Present:
Smt. B.Giri, President (I/C)
Sri Bharat Bhusan Das (Member)
Advocate for complainant – S.K Rout & G.D Mohanta
Advocate for OP-Alok Mahanta & Mamita Patra
Date of hearing -16.01.2020 Date of Order 22.07.2020
B.Giri President (I/C) - The brief facts of the case is that in order to secure the life complainant made a health Insurance of Rs 3,00,000/-(Three lakh) with opposite party Insurance company vide police No.30573236201600 for a period for one year i.e from 30.08.2016 to 29.08.2017 and during subsitance of policy the complainant to save the life of her husband compelled to donate one of her kidney at Appollo Hospital,Hydrabad for which she spent huge money in Appollo Hospital and for reimbursement of the medical expenditure the complainant initially claimed Rs 62,272/- on 19.11.2016 from Op Insurance by submitting medical documents and out of claim amount of Rs 62,272/- the Op Insurance company sanctioned Rs 60,223/- in favour of the complainant through NEFT in the Account No 29700010100386 of Corporation Bank,Keonjhar Branch which stands in the name of her husband without alleging any disease or any other plea from their side and after completion of kidney donation and recovery from ailments the complainant has claimed her final claim amounting to Rs 2,44,792/- for reimbursement from Op Insurance company on dt 22.2.2017 by depositing all relevant documents i.e bills of medical expenses of the Appollo Hospital,Hydrabad.But the Op Insurance company was rejected/repudiated the claim of complainant alleging that the complainant was suffering from “Hypertensive and cerebrovascular” disease prior to taking Insurance policy and intimated the Op through their letter dt 04.05.2017 as such the complainant sent a legal notice to Op Insurance company through her counsel on 18.01.2018 which was received by OP in 23.01.2018 but despite receipt of notice remained silent and intentionally avoid to pay the claim amount to the complainant causing mental and physical harassment to the complainant and hence this complaint for a direction to Op Insurance company to pay a sum of Rs 2,44,792/-with 18%
Interest from 22.02.2017 to till the actual payment is made in favour of the complainant and Rs 20,000/- towards compensation for mental shock harassment and agony, with cost of litigation besides any other relief found fit and proper.
After service of notice the Op raised a preliminary issue stating that complainant has for some strange and unnecessary reason impleded the CEO/Managing Director as Op respectively in the complainant.
On the other hand the Ld. Counsel for the complainant submitted that the CEO/MD is none other than the founder of the Health Insurance Scheme in question. The CEO/MD and the Max Bapu Health Insurance Company are two side of a coin and hence they are jointly and severally liable to compensate.
And as the Op failed to produce any document to prove the legal entity of Op as on independent body to sue or be sued. we have no doubt that the above petition is not tenable.
The Op in his version raised question regarding maintainability of this case challenging the territorial jurisdiction of this forum to entertain the present complaint as well as non discloser of Hypertension since 4 years and concealed the same as such she violates the term and conditions of the policy and further stated that complainant has submitted 2 claims one claim bearing number 221868 for an amount of Rs 60,223/- which was approved and paid since insured was admitted with a complaint of hematuria and 2nd claim filed under same policy vide claim No-237827 when she admitted in Apollo Hospital from 01.12.16 to 07.12.16 and the said was rejected as per clause 2.7 of policy guideline as the in surved complainant was a voluntary donor of kidney for her husband and also relied upon various decisions of Hon’ble Appex court and Hon’ble National Commission and prayed to reject the prayer of the complainant.
From the above submission the following issued framed for proper adjudication of the present case.
- That whether this forum has territorial jurisdiction to entertain such complaint or not.
- Whether the complainant suppressed her ailments prior to taking policy.
- Whether rejection of claim as per clause 2.7 of policy terms and conditions is genuine or not.
On the point of territorial jurisdiction the learned. Counsel for the complainant submitted that the contract of Insurance made through on line payment at Keonjhar and hence this Forum has ample jurisdiction to entertain the same and on the other hand on behalf of Op the submission made in its version to this point is that the complainant has not disclosed any cause of action to proceed against the op and in absence of the same the present complainant is liable to be dismissed.
The submission of complainant that the contract made through on line payment at Keonjhar and Op has not filed any document to rebate the said submission we hold that as the payment made from Keonjhar this forum has jurisdiction to entertain the present complaint.
As regard to suppression of ailment the Op has relied upon the statement of one mitali madhusmita who stated before the insurance company that the claimant Anima Madhuri Dutta is known case of Hyper tension Since 4 years and using “stamto” Tab 40 mg but on perusal of all the medical certificate no where it is found that the complainant is suffering from any such disease since last 4 years and the affidavit filed on behalf of Mitali Madhusmita dt 20.08.18 where she clearly averred that on 15.12.16 while complainant was taking bed rest representative of op motivated this complainant to fill up self declaration form but when she expressed her inability the representative of Op forced this mitali Madhusmita to fill up the self declaration form and it was filled as per dictation of Op’s representative and hence the self declaration form is doubtful and hence not taken to consideration. The next important point is that the repudiation is as per 2.7 of the with terms and conditions of the policy is whether genuine or not.
In this connections learned. Counsel for the complainant submitted that the repudiation of second claim while allowing the first claim on the same cause of action can not sustained in the eye of law and the repudiation of 2nd claim is intentional and deliberate just to avoid payment of a claim amount to the complainant by Op.
On the other hand we perused the terms and condition of the policy under clause 2.7(which is in page 285 of this record)
Where its mentioned:-
Organ Donor-
We will covered medical Expenses for an organ donor’s treatment for the harvesting of the organ do noted provided that:-
- The donation confirms to the transplantation of Human organ Act 1994 and the organ is for the use of the Insured persons.
- The Insured person has been medically advised to undergo an organ transplant.
We will not cover:-
- Pre hospitalization or post hospitalization Medical expenses or screening expenses of the donor or any other medical expenses as a result of the harvesting from the donor.
- Costs directly or indirectly associate with the acquisition of the donor’s organ.
Here the complainant is the wife of the insured and medically declared to be donor of kidney to her husband and medically advised to undergo an organ transplant to save her husband’s life and donation conforms to the transplantation of Human Organ Act and the organs is for the use of the insured person and hence cover under the policy conditions. Apartfrom that the medical expenditure claimed is not for pre-hospitalization or post hospitalization expenses and the claim is not for the cost which directly or indirectly associated with, the acquisition the donor’s organ and hence it is very much clear that the complainant’s claim is genuine and repudiation of claim by Op is illegal and arbitrary having no foot to stand and hence petitioner is entitled for the medical expenditure incurred for her donation of kidney to her husband.
Hence, Op (Insurance Company) is directed to pay the complainant a sum of Rs 2,44,792/-(Rupees two lakh forty four thousand seven hundred ninety two) towards medical expenditure against the policy and a sum of Rs 5000/- towards cost and compensation for mental agony and harassment within 30 days of receipt of this order or else the entire amount will carry 10% interest till realization.
The case is accordingly disposed of.
Pronounced on 22th July 2020
I agree
( Sri B. B. Das) ( Smt B. Giri)(M)
Member (I/C.,President)
DCDRF,Keonjhar DCDRF,Keonjhar
Dictated & Corrected by
( Smt B. Giri)(M)
(I/C.,President)
DCDRF,Keonjhar