West Bengal

Bankura

CC/120/2015

Sri Nitya Gopal Banerjee - Complainant(s)

Versus

Branch Manager, The Life Insurance Corporation of India - Opp.Party(s)

Self

22 Mar 2023

ORDER

IN    THE   DISTRICT   CONSUMER   DISPUTES   REDRESSAL COMMISSION BANKURA

Consumer  Complaint  No. 120/2015

Date of Filing : 08.10.2015

Before:

1. Samiran Dutta                              Ld. President.      

2. Rina Mukherjee                          Ld. Member. 

3. Siddhartha Sankar Bhui            Ld. Member.

 

For the Complainant: Ld. Advocate Ananada Mohan Mandal

For the O.P. Ld. Advocate Ashim Kumar Mondal

 

Complainant                                                                                                          

Sri Nitya Gopal Banerjee, S/o Late Anil Kr. Banerjee, Vill Jaldobra,Khatra, Bankura

Opposite Party  

1.The Branch Manager, LICI, Khatra, Bankura   2.The Sr.Divisional Manager, LICI, G.T. Road, Asansol  3.Dr. Asit Ahmed, Medical TPA Services Pvt. Ltd, Bishop Lefroy Rd., Kol- 20

FINAL ORDER / JUDGEMENT  

Order No.42                                                                                   

Dt. 22-03-2023

Both parties filed hazira through advocate.

The case is fixed for argument.

After hearing arguments/written arguments from both sides the Commission proceeds to dispose of the case as hereunder: -

The complainant’s case is that the complainant has a LIC Health Protection Plus Policy for self and his wife Ashima Banerjee vide Policy No.468480104 commencing from 13-01-2019 and expiring on 13-01-2025 with Yearly premium of Rs.7,500/- issued by O.P./LICI. While the policy was in force the spouse of the insured i.e. said Ashima Banerjee having her abdominal pain and swelling for seven days visited the Christian Medical College (CMC), Vellore and was admitted there on 21-10-2013 and after clinical examination she was operated on 23-10-2013 for incisional hernia and was discharged on 25-10-2013 from the said hospital and thereby Rs.28,629/- has been incurred as the medical expenses and hospitalization bills but the reimbursement of the same has been refused by the O.P./LICI authority. Hence this case.

                                                                                                                                                                                        Contd…….p/2

Page: 2

The O.P./LICI contested the case by filing a written version contending inter alia that the said Ashima Banerjee had pre-existing disease which she did not disclose in the Proposal form prior to the issuance of the Policy and as such the complainant is not entitled to get relief as prayed for.

-:Decision with reasons:-

Having regard to the facts of the case, documents on record and the contention and submission on both sides the Commission finds that the said Ashima Banerjee underwent surgical operation for incisional hernia at CMC, Vellore during the period from 21-10-2013 to 25-10-2013 and a medical expense of Rs.28,629/- has been incurred for the same as is evident from the relevant documents.

Ld. Advocate appearing for the O.P. has however referred to the Discharge summary issued by CMC, Vellore wherein said Ashima Banerjee was diagnosed with recurrent incisional hernia with the previous history in 1993 followed by incisional hernia repair in 2004 and total abdominal Hysterectomy in 2018. The Discharge summary is sufficient enough to indicate that the patient had already undergone hernia operation in 2004 and 2008 but suppressing the same the Policy was managed to be issued on 13-01-2009 and this solitary fact disentitles the complainant to get any benefit under the said Policy. In support of his contention he has referred to two decisions namely Civil Appeal No.3944 of 2019 of Apex Court and R.P. No.1616 of 2007 of NCDRC, New Delhi.

Ld. Advocate appearing for the complainant in support of the claim has produced relevant documents.

Admittedly the victim patient has been suffering from hernia since 2004 and she has to undergo treatment and operation for such hernia problem in 2004 and in 2008 but unfortunately the same hernia problem recurred in 2013 i.e. after about four years of the issuance of the Policy. If the nature of disease is recurring it cannot be construed as pre-existing disease as contended by the Ld. Advocate for the O.P.  Non-disclosure of the information regarding the treatment of such hernia disease in the Proposal form prior to the issuance of the Policy cannot be treated as suppression of material fact in strict sense of the terms and conditions of the Policy so as to disentitle the Policy holder.

Thus considering the above facts and circumstances of the case and the nature and character of the disease the complainant is entitled to get the relief as prayed for.

                                                                                                                                                                                        Contd…..p/3

Page: 3

Before concluding the order the Commission likes to place on record that the Commission is flooded with similar type of cases where plea of pre-existing disease and non-disclosure of the same in the Proposal form is generally taken on behalf of the Insurance Company and different decisions are cited to substantiate the plea and the claimants also take the plea in denial of the same citing various decisions.

Rulings & counter rulings and submissions & counter submissions sometimes mislead the Commission to come to the correct decision. Existing Insurance Laws on Pre-existing disease are clumsy and cumbersome.

It is high time for Insurance Regulatory and Development Authority of India to take holistic approach regarding the concept of Pre-existing disease in the settlement of  Insurance claim for speedy and effective disposal of claim cases.          

                                                                                            Hence it is ordered……

That the case be and the same is allowed on contest against the O.P.

The O.P.s are directed to pay to the complainant Rs.28,629/- within one month from this date in default the decretal amount may be realized in due process of law.

Both parties be supplied copy of this order free of cost.

Copy of this order be sent to the Chairman, Insurance Regulatory and Development Authority of India, Sy No. 115/1, Financial District, Nanakramguda,Gachibowli,
Hyderabad – 500032 for necessary action.

 

   __________________                 ________________               ________________

HON’BLE   PRESIDENT        HON’BLE    MEMBER       HON’BLE    MEMBER