: J U D G M E N T :
The brief fact of the case is that the complainant obtained an mediclaim insurance policy from OPs covering the period from 07.12.13 to 06.12.2014 with basic sum insured of Rs. 1,00,000/-. At the time of opening of the said policy the complainant was in a sound health. The said insurance has been obtained by the complainant through agent i.e., OP 2. Thereafter, suddenly the complainant was suffering from chest pain and doctor of N.H. Narayana Hospital advised him to do coronery angiogram on 15.04.14. Thereafter, the complainant went into R.N. Tagore Hospital on 06.05.2014 and the doctor advised him immediate admission as the operation of heart was very much essential. Then the complainant claimed the cashless benefit from OP Insurance Company i.e., OP 1. But OP 1 repudiated the said claim on the ground of pre-existing disease and also for non-disclosure of material fact. However, the complainant took admission in R.N.Tagore Hospital on 14.05.2014 and the bypass surgery was done on 19.05.2014. The bill for medical expenditure of Rs. 1,83,388/- has been raised for his medical treatment. The OP 1 denied the claim of cashless treatment vide letter dtd. 10.05.2014 causing clear case of gross negligence and deficiency in service on the part of OPs. hence, the complainant came before the Forum for getting proper relief.
OP 1 contested this case by filing written version stating, inter alia, that the insured / complainant has failed to disclose the material fact. The OP No. 1 rightly repudiated the claim on the ground of pre-existing disease as the insured / complainant had been suffering from hypertension since long period of time. Complainant did not file any claim form regarding reimbursement of medical expenditure. So there was no cause of action to file the said case. There is no gross negligence / deficiency in service on the part of the OP No. 1. So the petition is liable to be rejected with cost.
OP No. 2 also contested this case by filing written version stating, inter alia, that he approached to the complainant. The complainant filled up the proposal form at his house for obtaining mediclaim policy and signed the same. The complainant paid Rs. 5,000/- to the OP No. 2 i.e., agent of OP No. 1. This OP submitted that the complainant claimed the said amount for wrongful gain. So the petition is liable to be rejected with cost as there is no gross negligence /deficiency in service on the part of OP No. 2.
Now the Forum is to consider the following points:-
- Whether the complainant is to be treated as consumer or not as per
Consumer Protection Act 1986.
- Whether there is any gross negligence or deficiency in service on the part of OPs or not,
- Whether the complainant is entitled to get any relief as prayed for.
DECISION WITH REASONS
Point No. 1.
We have carefully perused the complaint, written version, evidence, written argument along with all relevant documents. It is admitted that complainant Sumit Mandal obtained the Sr. Citizen Red Carpet Insurance Policy being No. P/191116/01/2014/003352 covering the period on and from 07.12.2013 to 06.12.2014 with sum insured of Rs. 1,00,000/-. It is also admitted that the complainant obtained the said policy through OP No. 2 agent by paying the premium of Rs. 5,000/-. So both the OPs are service providers and the complainant is to be treated as consumer as per Consumer Protection Act, 1986. The point No. 1 is thus decided.
Point Nos. 2 & 3:
Policy being No. P/191116/01/2014/003352 covering the period on and from 07.12.2013 to 06.12.2014 with sum insured of Rs. 1,00,000/- is admitted. As per Annexure – 3 (operation note) it is clear that elective coronary artery bypass grafting was done on 19.05.2014 which is within the policy period. We have also perused the final bill issued by R.N. Tagore dtd. 28.05.2014. This bill reflects the net Hospital Charges of Rs. 1,83,688/-. Amount of Rs. 1,92,400/- was paid by the complainant and Rs. 8712/- was refunded by the Hospital authority. We have also perused the Annexure – 6. The OP Insurance Company has denied authorization of cashless treatment of the insured.
Now we try to find out the important point whether the suppression of material fact is involved or not in the instant case. On the date of proposal i.e., on 07.12.2013, the complainant informed that he was not suffering from any illness mentioned in the proposal form in earlier occasion i.e., it is presumed that the complainant was fit at the time of proposal. Ld counsel for OP argued that the insured had a history of hypertension since 4 years. In this regard it is our view that being a layman the complainant has no knowledge of medical science. He is a layman having no idea regarding symptoms of any disease as he is not a doctor or a medical expert. It may be noted that any symptoms are existed or involved in the human body. But he is not aware regarding this symptoms and when he is not aware then it cannot be said that complainant tries to suppress the material fact. Furthermore, that the OP Insurance Company in this regard has failed to submit any single document or doctor’s prescription stating inter alia, that he was suffering from disease / hypertension since four years or before endorsing the proposal form or has failed to adduce any evidence in support of their plea taken in written version. So mere declaration in proposal form does not prove the suppression of material fact from the end of complainant.
In LICI vs. Shri Niwas Bansal II (2013) CPJ 493 (NC), Hon'ble National Commission held that as per policy clause the complainant was entitled to reimbursement in case of bypass surgery in open heart.
In Abdul Vs. N.I.C. 2015 (1) CPR 69 (NC), wherein Hon'ble National Commission held that Insurance Company cannot repudiate a genuine claim on specious ground.
In this context it is pertinent to cite the observation of the Hon'ble Apex Court in the case of Bimal Krishna Bose, v. United India Insurance Company Limited and others, reported in III (2001) CPJ 10 (SC). The Hon'ble Supreme Court had observed in the following manner.
- That the Insurance Companies are ‘state’ within the meaning of Art. 12 of the constitution of India and they are expected to act fairly and reasonably.
- That the Insurance Companies are required to satisfy the requirement of reasonableness and fairness while dealing with customer. They must not take any irrelevant and extraneous consideration while arriving to a decision. Arbitrariness should not appear in their actions or decisions.
So, in the instant case the OP, Insurance Company is bound to pay the amount of medical expenditure to the complainant as the insurance policy is an agreement between the parties which is based upon the principle of uberima fide, i.e., utmost good faith.
So from the above observations we have come into conclusion that the instant case has a strong stand to believe the truth of event as well as the said case is very much genuine one. So the repudiation by the Insurance Company is baseless and has no basis at all causing gross negligence and deficiency in service on the part of OP Insurance Company.
It is duty of the OP No. 2 to collect the premium from the customer and to submit the same in the office of OP Insurance Company. This has been correctly complied with by the OP No. 2. The OP No. 2 has no responsibility for settlement of the dispute between the parties regarding reimbursement of medical expenditure. The complainant is entitled to get relief from the end of OP Insurance Company i.e., OP No. 1 as there is a clear gross negligence and deficiency in service on the par of OP No.1. The point Nos. 2 & 3 are thus decided. The case succeeds.
Hence,
Ordered,
That the case CC/2014/126 be and the same is allowed on contest against OP No. 1, Insurance Company with cost of Rs. 2,000/- and dismissed against OP No. 2 without cost.
That the OP No. 1, Insurance Company is hereby directed to pay Rs. 1,00,000/- as awarded amount plus Rs. 2,000/- as litigation cost along with compensation of Rs. 8,000/- for physical and mental harassment i.e., total of Rs. 1,10,000/- to the complainant within 30 days from the date of order, in default, the decretal amount shall carry interest @ 10% pa till full realization.
Let the copy of this order be supplied to the parties free of cost.
