Date of filing : 08.06.2017.
Decided on : 19.02.2020.
JUDGEMENT
Bibekananda Pramanik, President – This consumer complaint under section 12 of C.P. Act, 1986 has been filed by the complainant Anup Kumar against the O.Ps. named above alleging deficiency in service on the part of the O.Ps.
Complainant’s case, in brief, is as follows :-
O.Ps. deal with the business of issuing health insurance policy to different individual, in exchange of consideration and in course of their said business, O.P. no. – 1 issued a Family Health Optima Insurance Plan Policy bearing No. P/191113/01/2017/001451 valid for the period from 29.06.2016 to 28.06.2017 covering the risk of inpatient treatment cover hospitalization expenses for a total sum insured value of Rs. 4,00,000/- in favour of Kameswar Singh, the father of the complainant, being the head of the family. The said policy is a renewal of earlier policy bearing No. P/191113/01/2016/001287. During subsistence of that policy, the complainant was admitted in Ekbalpur Nursing Home Pvt. Ltd., Kolkata and he was operated there on 19.07.2016 under SA for Stricture Urethra with Luts and subsequently he was discharged on 20.07.2016. On discharge the complainant had to pay Rs. 62,000/- to the said Nursing Home as per their final bill dated 20.07.2016. Eight days thereafter the complainant again experienced bleeding in urine and he was further admitted in the said Nursing Home on 29.07.2016 and he was discharged on 14.08.2016. For such treatment the complainant had to pay Rs. 34,350/- to the said Nursing Home. Subsequently the complainant submitted claim form together with all bills and receipts to the O.Ps. for total claim of Rs. 1,45,084/-. After long delay, the O.Ps. by sending a letter dated 02.11.2016 repudiated the claim on pretext that the claim is not payable as per exclusion clause no. 3 of the subject policy. It is stated that the O.P. Insurance Company has caused deficiency in service in repudiating the genuine claim of the complainant. Hence the complaint, praying for directing the O.Ps. to disburse the claim of Rs. 1,45,084/- to the complainant towards expenses of hospitalization under the subject policy and for an order of compensation of Rs. 50,000/- and litigation cost.
All the O.Ps. have contested this case by filing a joint W/V.
Denying and disputing the case of the complainant, it is the specific case of the O.Ps., as made out in their W/V, that the complainant was admitted on 15.07.2016 in Ekbalpur Nursing Home Pvt. Ltd., Kolkata – 700 023 for treatment of “Stricture Urethra with Luts” and he was discharged from said Nursing Home on 20.07.2016. Said Nursing Home raised a pre-authorization request on 15.07.2016 for Rs. 25,750/- for availing cashless facility for the treatment of “Stricture Urethra with Luts” of the complainant and the O.Ps. denied such request vide a denial letter dated 18.07.2016 and the same was communicated to the said Nursing Home on the same day. The reason of denial was given as per Exclusion No. 3(a) of the policy in question as the company is not liable to make any payment in respect of any expenses incurred by the insured person for treatment of all diseases of Prostate, Stricture, Urethra and all obstructive Uropathies during the first 2(two) years of continuous operation of the insurance cover. After discharge from the said nursing home, the complainant submitted his claim for reimbursement of such treatment for an amount of Rs. 1,45,084/- before the O.Ps. and the said claim of the complainant was rejected by the O.Ps. as the company is not liable to make any payment as per Exclusion Clause No. 3(a) of the said policy in respect of any expenses of such treatment of Stricture Urethra during the first 2(two) years of continuous operation of insurance cover. It is therefore stated by the O.Ps. that by such repudiation of claim of insurance they did no illegality and there is no deficiency in service on the part of the O.Ps.
Both parties have filed respective evidence supported by affidavit in support of their case.
POINTS FOR DECISION
- Is the case maintainable in its present form and prayer?
- Is the complainant a consumer of the O.Ps.?
- Is there any deficiency in service on the part of the O.Ps.?
- Is the complainant entitled to get the reliefs as prayed for?
DECISION WITH REASONS
Point No.-1: Maintainability of this case has not been questioned by any of the parties at the time of final hearing of the case. We also find nothing adverse regarding maintainability of this case. This point is accordingly decided in favour of the complainant.
Point No.-2: It is not denied and disputed that the O.Ps. carry on their business of issuing health insurance policy to different individual in exchange of consideration and in course of their such business, they issued a Family Health Optima Insurance Plan Policy of Rs. 4,00,000/- in favour of Kameswar Singh, the father of the complainant, who took such policy as head of his family. The complainant, being the son of said Kameswar Singh and a member of the family of insured Kameswar Singh, is definitely a consumer of the O.Ps. This point is accordingly decided in favour of the complainant.
Point No.-3: From the respective pleadings of the parties we find that admittedly the complainant was admitted on 19.07.2016 in Ekbalpur Nursing Home Pvt. Ltd., Kolkata – 700 023 and he was operated there on 19.07.2016 under S.A. for Stricture Urethra with Cuts and he was discharged from that Nursing Home on 20.07.2016. It is also undisputed that again on 29.07.2016, the complainant was admitted in the said Nursing Home as he experienced bleeding in urine and he was treated there for his such ailment. Fact also remains undisputed that after discharge from the said nursing home, the complainant submitted claim form together with receipts for reimbursement of medical expenses of Rs. 1,45,084/-. Grievance of the complainant is that his said claim was illegally repudiated by the O.P.- Insurance company and such act of the O.P. amounts to deficiency in service. As against this, it is the case of the O.Ps. that as admittedly the complainant was admitted in the said nursing home for operation of Stricture Urethra with Cuts, so in view of Exclusion 3(a) of the policy in question, the complainant is not entitled to get any reimbursement of such medical expenses. From the policy in question we find that in Exclusion Clause No. 3(a) of the said policy it has been specifically stated that during the first 2(two) years of continuous operation of the insurance cover, any expenses on all diseases of Prostate, Stricture Urethra etc. the company is not liable to make any payment of such treatment. It is the settled law that since the insurance between the insurer and the insured is a contract between the parties, the terms of the agreement including applicability of the provision and also its exclusion had to be strictly construed to determine the extend of the liabilities of the insurer.
In view of that and in view of Exclusion 3(a) of the policy in question the complainant is not entitled to get any payment under the policy for his such treatment of Stricture Urethra and by repudiating such claim of payment, the O.P./Insurance Company committed no illegality and their such act is not deficiency in service.
This point is accordingly decided against the complainant.
Point No.-4: In view of our above findings under point no.-3, the complainant is not entitled to get any relief. This point is therefore decided against the complainant.
All the points are accordingly disposed of.
In the result, the complaint case fails.
Hence,
it is,
O R D E R E D
that Complaint Case No. 173/2017 is dismissed on contest without cost.
Let plain copy of this order be given to the complainant free of cost.
Dictated and corrected by me.
( Bibekananda Pramanik )
President, D.C.D.R.F., Howrah.
