- Mrs. Damyanti M. Mehta,
- Mrs. Varsha Maniar,
Both residing at
25/1C, Mohini Mohan Road,
Kolkata-20, P.S. Bhowanipur._________ Complainants
____Versus____
- Branch Manager,
Star Health and Allied Insurance Co. Ltd.
200/2C Rashbehari Avenue, 3rd Floor,
P.S. Gariahat, Kolkata-29.
- Star Health and Allied Insurance Co. Ltd.
Represented by Chief Manager
Kolkata Branch
75C, Park Street, 6th Floor,
Present : Sri Sankar Nath Das, Hon’ble President
Dr. Subir Kumar Chaudhuri, Member.
Smt. Samiksha Bhattacharya, Member
Order No. 19 Dated 29/03/2016.
The case of the complainants in short is that complainants are the sisters of Bhogilal Vora, S/o Late Jayentilal Vora who was a widower and died intestate on 20.2.13 without leaving any issue. That Bhogilal Vora had taken a Senior Citizen Red Carpet Insurance Policy on 11.1.10 from o.p. no.1 and paid premium of Rs.9326/-. Prior to the expiry of the first policy period the said Bhogilal Vora renewed the policy on 21.12.11 by making second premium of Rs.9326/- and again he renewed the policy third time on 31.12.12 on payment of Rs.9500/-. Bhogilal Vora was suffering from spinal decomposition and he required ‘spinal surgery for decomposition and fixation for caries’ and was admitted to Fortis Hospital on 29.11.12. On 1.12.12 Dr. Vijay Kumar operated him and made Universal Ortho-system Titanium implant. After completion of post operative observation and medication Bhogilal Vora was discharged on 8.12.12. During the policy period i.e. on 1.1.13 the insured Bhogilal Vora had lodged a claim for payment of medical bills borne by him for his operation at Fortis Hospital amounting to Rs.2,56,555/-. After release from Fortis Hospital Bhogilal Vora was residing at 37/2, Balaram Bose Ghat Road, Kolkata-29 where he died subsequently on 20.2.13 due to cardio respiratory failure after having septicemia and Koch’s Spine. During the lifetime of Bhogilal Vora o.p. no.1 kept the claim pending without assigning any reason. After the death of Bhogilal Vora complainants requested one Mr. Minesh Maniar to follow up the claim on behalf of complainants. After several follow up by Minesh Maniar o.ps. informed vide their e-mail dt.7.3.13 that the disease of Bhogilal Vora was pre-existing which was not disclosed and therefore, the claim had been repudiated. Complainants stated in their petition that Bhogilal Vora had an old history of epilepsy but he was not under treatment or medication and epilepsy cannot be said to be a pre existing disease as he was not suffering from said complication for the last 10 to 15 years prior to his death. On 16.4.13 complainants sent advocate’s letter to o.ps. but o.ps. kept them silent. On 1.6.13 complainants again sent a letter. On 20.6.13 complainants received a letter dt.17.6.13 from Claim Manager of o.p. no.2 wherefrom it reveals that they wanted to justify their stand to repudiate the claim by making various incorrect and false reasons. Finding no other alternative complainants filed the instant case praying for mediclaim amount of Rs.2,56,555/- along with compensation.
O.ps. appeared in this case by filing w/v and denied all the material allegations interalia stated that the repudiation of the claim was just and justified as the insured failed to disclose the pre existing disease at the time of inception of the policy. It reveals that the disease was of pre existing in nature, so the claim of the insured cannot be entertainable. However, they have mentioned in the w/v that if the claim of the deceased be considered then the extent of the amount would be Rs.1,15,500/- as per deduction followed by exclusion clauses of the policy in question. They have categorically mentioned the reasons for deduction in their w/v. The amount of Rs.1,15,500/- is the maximum amount for which the deceased would claim, so the present case has got no merit and the same is liable to be dismissed.
Decision with reasons:
We have gone through the pleadings of the parties, evidence and documents in particular. The moot question for consideration is whether the present complaint petition is maintainable or not. Complainants stated in their petition that they are sisters of insured Bhogilal Vora who died on 20.2.13. Though the claim was lodged by Bhogilal Vora but in his life the claim had not been settled. After his expiry present complainants contacted with o.ps. We have not found any document which shows that these two complainants are the sisters and only legal heirs of insured Bhogilal Vora. Complainants did not file any document showing their locus standi to show their eligibility to claim for the policy amount towards hospitalization bills of the insured. Moreover, the evidence had been filed by the authorized representative of complainants, not by complainants themselves. Complainants did not file any succession certificate or whatsoever towards their locus standi to file the instant case. In view of above, complainants had failed to substantiate their case and are not entitled to relief.
Hence, ordered,
That the case is dismissed on contest without cost against the o.ps.
Supply certified copy of this order to the parties free of cost.
