IN THE COURT OF THE LD. DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT S I L I G U R I.
CONSUMER CASE NO. : 44/S/2015. DATED : 07.12.2016.
BEFORE PRESIDENT : SRI BISWANATH DE,
President, D.C.D.R.F., Siliguri.
MEMBERS : SMT. PRATITI BHATTACHARYYA &
SRI PABITRA MAZUMDAR.
COMPLAINANT : MR. RAJU SARKAR,
S/O. Late Narayan Chandra Sarkar,
Resident of C/o. Sarkar Automobiles,
Sevoke Road, P.O.- Sevoke Road,
P.S.- Siliguri, Dist.- Darjeeling.
O.Ps. 1. : BAJAJ ALLIANZ GENERAL INSURANCE CO.
LTD.,
A Company registered under the Companies Act,
1956, having its registered office at
GE Plaza, Airport Road, Yerawada, PUNE – 411 006
and also having its branch office at Saharan House,
2nd Mile Sevoke Road, P.O. & P.s.- Siliguri,
Dist.- Darjeeling.
2. : THE BRANCH MANAGER,
Bajaj Allianz General Insurance Co. Ltd.,
having his office at Saharan House, 2nd Floor,
above ICICI Bank, 2nd Mile, Sevoke Road,
P.O. & P.S.- Siliguri, Dist.- Darjeeling.
Proforma OPs. 3. : APOLLO GLENEAGLES HOSPITALS,
having its office at 58, Canal Circular Road,
Kolkata – 700 054.
4. : DR. DEBASIS GHOSH,
Cardiologist of Apollo Gleneagles Hospitals,
Kolkata, having his Chamber/OPD at 58,
Canal Circular Road, Kolkata – 700 054.
FOR THE COMPLAINANT : Sri Rathin Sarkar, Advocate.
FOR THE OP Nos.1 & 2 : Sri Kanak Lal Kundu, Advocate.
FOR THE OP No.3 : Sri Satadal Gupta, Advocate.
FOR THE OP No. 4 : Sri Bijoy Saha, Advocate.
J U D G E M E N T
Sri Biswanath De, Ld. President.
The complainant’s case in a brief is that the complainant and his family members made Health Guard Policy No.OG-14-240406009-00000338. The
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said policy was extended from 16.03.2013 to 15.03.2014 and latter on was extended to 14.03.2015 with some cost. Health and Wellness Cards were issued. The condition of the policy was cashless and reimbursement facility to the complainant. In the middle of March, 2014, the complainant became ill and unconsciousness. He was treated. OP No.4 suggested for implantation of permanent pace maker. The complainant incurred expenditure of Rs.2,49,365.15 paisa.
After treatment the complainant approached before the OP No.1, OP No.2 for reimbursement. But the OPs repudiated the claim of the complainant. Hence, the complaint.
The OP appeared and filed written version denying inter-alia all the material allegations as raised by the complainant. The OP admitted that they issued the policy to the complainant containing the terms and condition, exception and limitation was issued to the complainant at the time of subscribing the policy. It is also stated that policy was issued as per attached proposal form and terms and conditions for the policy in time. It is further case of the OP that the claim documents show that the complainant was hospitalized for the Treatment of Recurrent Syncope. The complainant is known to be suffering from Recurrent Syncope and he had similar episode 15 years back and had three episodes of Syncope over last three years which is pre-existing to the policy and has not been disclosed in the proposal form. The OP further states that in the exclusion clause C1 of the policy specifically states Benefits will not be available for any Pre-existing condition, ailment or injury until 48 months of continuous coverage have elapsed, after the date of inception of the first Health Guard policy with us (OP). The above exclusion shall cease to apply if you have maintained a health Guard Policy with the OP insurance company for a continuous period of a full four years without break from the date of your first health Guard policy of the insured with the Insurance company. Hence, the complaint is liable to be dismissed.
To prove the case the complainant has field the following documents :-
1. Photocopy of letter issued by Authorized Signatory of the OP No.1 in the name of the complainant.
2. Photocopy of patient discharge record issued by Apollo Gleneagles Hospitals, Kolkata.
3. Photocopy of the bill dated 26.05.2014 issued by the OP No.3.
4. Photocopy of money receipts issued by the OP No.3
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5. Photocopy of letter dated 17.05.2014 issued by the authorized signatory of the OP No.1.
6. Photocopy of repudiation letter dated 10.06.2014 issued by the OP No.1.
7. Photocopy of details history, physical record and clinical information of the complainant.
OP No.1 & 2 filed the following documents :-
A) Family Floater Health Guard – Proposal Form signed and submitted by the complainant.
B) Generic Contingency Policy Schedule bearing Policy No.OG-13-2404-6001-00000454 in the name of Sri Raju Sarkar, valid from 16.03.2013 to 15.03.2014 and 15.03.2014 to 14.03.2015.
C) Star Package Proposal Form signed and submitted by the complainant.
D) Progress Report, Inpatient Medication Record and Doctor Instruction Sheet in respect of Raju Sarkar issued by Apollo Gleneagles Hospitals, Kolkata.
E) History & Physical Record of Raju Sarkar issued by Apollo Gleneagles Hospitals, Kolkata.
F) Report of Permanent Pacemaker Implantation issued by Apollo Gleneagles Hospitals, Kolkata.
G) Discharge Summary in respect of Sri Raju Sarkar issued by Apollo Gleneagles Hospitals, Kolkata.
H) Repudiation letter issued by the OP, Insurance Company to the complainant.
Complainant has filed evidence-in-chief.
OPs have filed evidence-in-chief.
Complainant has filed Written Notes of Argument.
OPs have filed written notes of argument.
Complainant has filed the following citations :-
i) C.P.J. 2015, Vol-IV, Page No.-407, NATIONAL COMMISSION.
ii) C.P.J. 2014, Vol-III, Page No.-340, NATIONAL COMMISSION.
III) C.P.J. 2013, Vol-II, Page No.-10, NATIONAL COMMISSION.
IV) C.P.J. 2016, Vol-II, Page No.-244, NATIONAL COMMISSION.
OP Nos.1 & 2 have filed the following citations:-
i) VOL-IV (2009) CPJ 8 SUPREME COURT.
ii) VOL-IV (2006) CPJ 1 SUPREME COURT.
iii) VOL-I (2009) CPJ 6 SUPREME COURT.
iv) VOL-II (2016) CPJ 132 NATIONAL COMMISSION.
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v) VOL-I (2016) CPJ 649 NATIONAL COMMISSION.
vi) VOL-I (2015) CPJ 523 NATIONAL COMMISSION.
vii) VOL-II (2015) CPJ 654 NATIONAL COMMISSION.
viii) VOL-III (2015) CPJ 474 NATIONAL COMMISSION.
ix) VOL-IV (2015) CPJ 529 NATIONAL COMMISSION.
x) VOL-II (2014) CPJ 615 NATIONAL COMMISSION.
xi) VOL-III (2014) CPJ 190 NATIONAL COMMISSION.
xii) VOL-III (2013) CPJ 684 NATIONAL COMMISSION & others.
Points for determination
1. Is there any deficiency in service on the part of the OPs ?
2. Is the complainant entitled to get any relief as prayed for ?
Decision with reason
Both issues are taken up together for the brevity and convenience of discussion.
It is admitted position that complainant was insured by the OP No.2. The OP Nos.1 & 2 stated that the complainant deliberately did not disclose his medical history past illness in the proposal form submitted to the OP Insurance Company. The complainant was suffering from Recurrent Syncope and he had similar episode 15 years back. The exclusion states that benefit will not available for any pre-existing condition, ailment and any injury until 48 months of continuous coverage have elapsed after the date of inception of the first Health Guard Policy with us.
The written version of OP No.4 doctor shows that the complainant has history of Recurrent Loss of Consciousness. Such statement has not laid down at the time of policy making. In the proposal form, the complainant did not whisper any type of disease which has been stated by the OP No.4.
Accordingly, after deliberation over the point in controversy, the proposal form does not support the complainant rather supports the contention of OP Nos.1 & 2 that complainant did not disclose any disease in the proposal form. The OP Nos.1 & 2 have cited principle of law written hereinbefore. Those principles of law support the contention of OP Nos.1 & 2 and supports also the correctness of repudiation of claim of complainant.
In the result, the case fails.
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Hence, it is
O R D E R E D
that the Consumer Case No.44/S/2015 is dismissed on contest against the OPs but without cost.
Copies of this judgment be supplied to the parties free of cost.
-Member- -Member- -President-
