Ld. Advocate(s)

                                    For Complainant: Makbul Rahaman

                                    For OP/OPs : Raj Kumar Mondal

            Date of filing of the case                       :26.04.2018

            Date of Disposal  of the case               :18.01.2024

Final Order / Judgment dtd.18.01.2024

          The concise fact of the case of the complainant is that  the

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complainant Nazrul Hossain  purchased  one Medical Policy on 29.11.2010 and continued till the  28.11.2011 vide policy no.03/602/84/10/97/00000498 of United India Insurance  Company Limited which was  renewed  on 29.11.2011 upto 28.11.2012 and further  it was renewed  upto 28.11.2013. The said policy further continued upto  28.11.2015. Thereafter, the OP No.4 Mr.  Ramkrishna Dey agent of Star Health  and Allied  Insurance Company requested the complainant  to port the said Insurance Policy from  OP No.3 United India  Insurance Company to OP NO.1 Star Health and Allied  Insurance Company. The said policy continued  from 29.11.2015 to 28.11.2016 as family  Health Optima  Insurance  plan, date of commencement  29.11.2015 premium Rs.13,845/- vide policy no.P/191123/01/2016/002262. The said policy covered the principal insured Nazrul Hossain  and his spouse  and his dependent  children  with coverage  of Rs.4,00,000/- valid upto  28.11.2016. During the continuance of the policy  the policy holder  Nazrul Hossain  suddenly  failed chest pain  and medically treated  at NH Rabindranath  Tagore  International Institute  of Cardiac Sciences  Mukundapur , Kolkata and ECG was done on 03.02.2016. Thereafter,  the complainant  was admitted on 04.02.2016 under Dr. Radheshyam Joshi and discharged  on 06.02.2016. The said doctor advised  the complainant for  urgent heart operation.  The complainant claimed  to the OP No.1 through the said  Rabindranath  Tagore  Hospital  Mukundapur  for getting his cashless  benefit  as his policy was  cashless.  OP NO.1 sent a letter  to Rabindranath  Tagore  Hospital  on 06.02.2016 but they denied for pre-authorisation cashless  treatment  on the ground that on scrutiny  of the detail the claim is not  admissible  for the reason :- TMT report dated July, 2014 which was before inception  of the policy. This was not  disclosed  during the policy  inception. Due to  non-disclosure  of fact  the claim  is not payable, so the  cashless treatment  of the insured  patient  was denied.  Subsequently,  the complainant  undergone  operation  at Medica Super speciality Hospital, Kolkata  on 08.02.2016.  He undergone  pump Elective Coronary Artery Bypass Grafting x 3 Grafts on 10.02.2016 and discharged  on 18.02.2016. The total amount of medical  treatment for that purpose  was Rs.42,335/- to N.H R.N. Tagore Hospital  and Rs.3,45,682/- for operation  and other expenses.  Thereafter,  the complainant sent  all bills  and copy of discharge  to OP No.1 through authorised agent OP NO.3. But no fruitful  result  came from the OP .  Subsequently , OP No.1 sent one  letter with  a demand draft  of Rs.5,915/- as refund  of premium  after  repudiation  of the claim. The OP No.1 thus arbitrarily and whimsically  rejected  the cashless claim  of the complainant.  The said repudiation  is not proper  because first  policy was started  in

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2010. So the present  case is filed . The cause of action for the present case arose  on 24.03.2016 and thereafter,  it is continuing  till the filing of this case.  The complainant  therefore,  prayed for an award  for a sum of Rs.3,45,682/- towards  mental pain, harassment and agony.

OP No.4 did not contest  the case. OP No.1&2 contested the case by filing W/V wherein  they denied  the major allegations. The positive defence case of the OP No.1&2 in brief  is that the complainant  availed  family health optima  policy from  29.11.2015 to 28.11.2016 for sell , wife Mrs. Mamotaz Begum  and dependent Mohammad Hossain  and Tania Sultana for Rs.4,00,000/- which was  ported  from United India  Insurance  Company (2010-2011 to 2014-2015). The terms and conditions  of the policy  were explained  to the complainant  at the time of proposing  policy  and the same was served to the  complainant  along with  the policy schedule. In the basis of the schedule  it is clearly mentioned that the insurance  under this policy  is subject to the  conditions,  clauses,  warrantees  etc.  The  insured patient  Nazrul Hossain  was admitted  on 04.02.2016 in Fortis R.N. Tagore  Hospital, Kolkata  and raised  a pre-authorisation  availing cashless for the treatment  of IHD. On receipt of pre-authorisation request it is observed  that as per pre-authorisation  form  the provisional  diagnosis  was IHD. CAG report shows left means triple vessel coronary uteri disease. ECHO shows mild systolic  dysfunction (on ECHO Cardiogram). The TMT dated 30.07.2014 (the prior to porting the policy) shows  positive. The above  finding confirmed  that the insured  had  heart disease  prior  to porting  policy  with the  OP.  At the time of porting  the policy insured did not disclose  the aforesaid  medical hospital  in the proposal form  which amounts to misrepresentation/non-disclosure  of material  facts. As per condition no.7 if there is any misrepresentation  the company  is not liable to make any payment  for the claim. Hence the pre-authorisation  request  for cashless authorisation  was denied.  The present case  is filed vexatiously. The  OP  NO.1&2 prayed  for dismissal of this case with  cost.

OP No.3 also denied  the major allegations and challenged the case  as not maintainable. The positive defence case  of OP No.3 in brief  is that the complainant  purchased  a Medi-claim  policy  from OP No.3 United India Insurance  Company  Limited  for the period 29.11.2014 to 28.11.2015 subject to the terms and conditions . The complainant  suddenly felt ill  and therefore medically  treated  from 03.02.2016 which is after the expiry  of the said policy  and as such the OP No.3 is unnecessary  party  so the OP No.3 is not liable  to pay

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any compensation. OP No.3 therefore,  prayed for  dismissal of the complaint  with cost.

The conflicting pleadings of both the parties led this Commission to ascertain the following points for determination.

Points for Determination

Point No.1.

          Whether the  case is maintainable  in its present form and prayer.

Point No.2.

          Whether the complainant  is entitled to get the relief prayed for.

Point No.3.

          To what other relief if any the complainant is entitled to get.

Decision with Reasons

Point No.1.

Both the Ops challenged  the case as not maintainable. It is the admitted  fact that the complainant was insured  with OP No.3 initially  and thereafter  the complainant ported  the said insurance  with the OP No.1 for the period  initially  from 29.11.2014 to 28.11.2015 and thereafter, from 29.11.2015 to 28.11.2016. There is no pleading  by either of the parties  that the said policy  was not  valid  or that it was discontinued.  The case record shows  that the porting of the policy was done  with continuation  of the said insurance  policy of the complainant.  Thus  the relation between the  complainant  and the Ops  is just like a customer /consumer  and service provider.

Although  OP NO.3 pleaded that the case is bad for defect  of  parties  but no argument  is advanced  or no evidence  is adduced  to substantiate  that point.

The pecuniary limit  of the relief  claimed  and the subject matter are  well in the  pecuniary  jurisdiction  of this Commission. There is nothing  in the case record in regard  to negative  aspect  of territorial jurisdiction.

Thus  having assessed the materials  in the case record  the Commission  is of the  view that the case  is legally maintainable in its present form and prayer.

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Point No.2&3.

Both the points are very closely interlinked with each other  and as such these points are taken up  together for brevity  and convenience.

The complainant in order to  substantiate  the case adduced both oral evidence  in the form of affidavit in chief  and documentary  evidence of the original insurance policy.

It is the admitted fact that the complainant  registered  the insurance policy  bearing no.03/602/84/10/97/00000498

It is also the admitted fact that the said policy was ported with Star Health  and Allied Insurance Company Limited bearing policy no. P/191123. Annexure-6 is the policy  under the OP No.1 Star Health  Allied Insurance  Company Limited  wherein  they registered  the said policy  with continuation  of previous  policy no.0316022814. The OP No.3 in their defence never denied that the previous policy  was defective  on any ground.

The original policy was started in the year , 2010. As per  clause 3.28 of Health Insurance  Policy  Gold  of the first policy  under OP No.3 “portability”  means transfer  by Individual Health Insurance Policyholder(including family cover) of the credit gained  for pre-existing  conditions  and time-bound exclusions if he/she chooses  to switch from one insurer to another.

In the existing case the complainant  ported  his previous  insurance  by following the provisions  of the bylaws  and regulations  of OP No.3.

Ld. Advocate for the complainant  rightly  argued  that in the  previous  policy there is specific  mentioning  that during the  validity  of the insurance  the complainant  shall get  the benefit  in any health  problem  under the said  scheme.  Ld. Advocate for the complainant  further argued that  the TMT was done  on 30.04.2014 prior  to that  the original policy  was registered  in 2010 and the said policy  was continued  after porting . So the complainant  will get the seniority  benefit .

The argument has reasonable force.

Ld. Defence Counsel  argued that  the complainant  is duty

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bound  to follow proposal for health condition  and must disclose  about any  ailment  of the complainant.  But he suppressed  the material fact. Insurance policy  is registered  on good faith  and credential  which the complainant  violated.

The said argument  is not acceptable  in as much as  there is nothing  within the four-corners of the case  record that the  OP No.1&2 claimed  any information  from the complainant  about disclosure  of his  previous-disease.

In this regard  Ld. Advocate  for the complainant  filed one  case law  reported  in the  case of Tarlok  Chand Khanna  Vs. United India  Insurance Company  Limited  in revision petition no.686 of 2007 passed by Hon’ble NCDRC wherein  it was held  that there is no record  produced by the  respondent  to indicate  that any such disease  existed  or pre-existing.  Onus  to prove  that the insured  had a pre-existing disease  there on the respondent. So in absence  of credible documentary or other  evidence  by the respondent  on whom there was onus  to prove  the reason  for repudiation  the revision  petition  is allowed.

The said case law is relied on .

The complainant also referred  to another case  law reported  in 2021 (3) CPR 409 wherein  it was held  by Hon’ble  NCDRC appellate  issued ported  medi-claim insurance policy  for continuation  of the previous policy. Policy was  questioned  for the first time  in repudiation letter. So the claim cannot be  rejected  for non-disclosure of material  fact.

The said case law  is applicable here because  the OP No1&2 company  for the first time  raised  that point of suppression of material  fact.

Ld. Defence Counsel  further referred  to another  decision of  Hon’ble Supreme Court  in Civil Appeal 3397 by 2020. Wherein  it was held  that if there is suppression  of material fact the repudiation  can be  upheld .

The said case law is not applicable  here in as much as  there is nothing  to show that the proposer/complainant  had prior to knowledge  such fact. That apart  the said  case is not related to any porting  of insurance.

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In view of the fact that the  OP failed to  substantiate  that the complainant caused suppression of material facts the present case law  is not applicable.

Ld. Defence Counsel  further referred  to some legal literature  regarding non-disclosure  of material facts. The said theory is not acceptable  in view of the fact  that the case law referred to by the Ld. Advocate for the complainant  rightly  go in favour of the complainant. Ld. Defence Counsel for the OP further argued  that as per no. Clause 11 if the complainant  had any knowledge  about the pre-existing  disease  he must disclose  it in the proposal form.

The said point 11 relates  to free look period  of 15 days  from the date of receipt  of the policy  regarding  the terms and conditions. There is nothing  within the  fout-corners  of the case record  that the complainant  violated  the said terms and conditions  of the said policy  manual. It is also found that the  complainant duly  fulfilled the  conditions  of portability  as per clause 12 of the  said insurance plan.

On the contrary  Ld. Advocate for the  complainant  rightly  argued  that the OP did not review  the policy within 30 days . He further argued  that is not possible  for the complainant  to assess  as to whether the  blood circulation  is proper  in the body of the complainant.

Thus having  assessed  the  pleadings of the both the parties  and the evidence  in the case record  the Commission finds that the  Ops  have  unfairly repudiated the claim of the complainant  which tantamount  to deficiency in service  and caused  mental pain and agony and harassment to the complainant.

The OP did not challenge  the amount claimed  for medical expenses  by the complainant  Rs.3,45,682/- . The documents filed by the complainant  in regard  to medical  expenses  is taken into  consideration and found that  the claim is fair and proper.

Accordingly,  point no.2 &3 are  answered  in favour of the complainant.

Consequently , the complaint case is disposed of on contest  with cost.

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Hence,

                              It is

Ordered

that the complaint case no.CC/64/2018 be and the same is allowed on contest  with cost against OP No.1-3 and ex-parte  against OP No.4. The complainant  Nazrul Hossain do get an award  for a sum of Rs.3,45,682/- (Rupees Three lakh forty five thousand six hundred eighty two) towards  actual medical bill  incurred , Rs.25,000/- (Rupees twenty five thousand) towards  mental pain, agony and harassment and Rs.5,000/-(Rupees five thousand) towards litigation cost. The OP No.1&2 are directed to  pay the said sum of Rs.3, 75,682/-(Rupees three lakh seventy five thousand six hundred eighty two) to the complainant within 30 days  from the date of passing  the final order  failing which  the entire award money shall carry an interest  @10% p.a from the date of passing  final order till the date of its realisation.

All Interim Applications  (I.A) stand disposed of  accordingly.

D.A to note in the trial register.

The case is accordingly disposed of.

Let a copy of this final order be supplied to both the parties at free of costs.    

Dictated & corrected by me

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                PRESIDENT

(Shri   HARADHAN MUKHOPADHYAY,)                                    ................ ..........................................

                                                                                                                          PRESIDENT

                                                                                              (Shri   HARADHAN MUKHOPADHYAY,)

I  concur,

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          MEMBER                                                                   

(NIROD  BARAN   ROY  CHOWDHURY)