IN THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BANKURA.
C. C. No.120 / 2014.
Present :
1. Abdul Kuddus……………………….Hon’ble President.
2. Smt. Agnidipa Agnihotri………….Ld. Member.
Sri Balabhadra Bag, S/o Late Brindaban Bag, R/o Hatmahatap Lane, Schooldanga, Bankura, P.O., P.S. & Dist. Bankura …………………………..............Complainant.
Versus
1. Branch Manager, The Oriental Insurance Company Ltd., Bidyabhaban, Floor
No.3rd., Bankura, P.O., P.S. & Dist. Bankura, Pin – 722101.
2. M/S. Heritage Healths, TPA Nicco House, 5th Floor, 2 Hare Street, Kol – 700001.
3. Regional Manager, Bangiya Gramin Bikash Bank, Bankura R.O., College Road,
Bankura, P.O., P.S. & Dist.Bankura. Pin-722101.………………..Opposite Parties.
Judgement
Dt. 01-09-2016.
Fact of the case of the Complainant in brief is that:- The Complainant purchased Mediclaim Policy from the Oriental Insurance Co. i.e. O.P. no.1 Company bearing Policy No.313106/48/2009/797 for the period 18-03-2009 to 17-03-2010 and the said policy was renewed from time to time by paying premium of the said policy. At the last time this Complainant paid Rs.1750/- vide Cheque No.017402 dated 15-03-2013 drawn in favour of Oriental Insurance Co. Ltd. / O.P. no.1 and the said cheque was received by the Manager of the O.P.no.1 Company on 16-03-2013 and acknowledged the same by putting his signature and office seal. But the impugned mediclaim policy bearing no.313106/48/2013/1184 was generated malafidely by the O.P. no.1 Insurance Co. for the period 26-03-2013 to 25-03-2014 instead of 18-03-2013. The said fact was brought to the knowledge of the O.P. no.1 Company for rectification of period of the said impugned policy.
The premium was paid vide cheque of Bangiya Gramin Vikash Bank before the due date for continuation of the said mediclaim policy. Complainant was treated by the Apollo Hospital, Chennai on and from 7th July, 2013 to 09-07-2013 and the cost of treatment was incurred to the tune of Rs.1,08,369.62. The Mediclaim Policy was purchased for Rs.1,00,000/-. So,
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applicant made claim along with documents regarding his treatment as well as payment for medical treatment to the O.P. no.1; but O.P. no.1 declined to pay any amount to this Insured applicant for his medical expenses. So, this applicant / Complainant has filed this complaint and prayed for compensation to the tune of Rs.1,00,000/- for his harassment, mental pain and agony, etc. against the O.P. no.1 & 2. And also prays for further sum of Rs.50,000/- for litigation cost against O.P. no.1 & 2.
O.P. no.1 is Branch Manager of the Oriental Insurance Co. Ltd. O.P. no.2 is the TPA and O.P. no.3 is the Regional Manager of Bangiya Gramin Vikash Bank.
No relief / claim has been prayed for against O.P. no. 3.
On the other hand this case is being contested by O.P. no.1 by filing W/V denying all allegations as made in the petition of complaint contending inter alia that the case is not maintainable. The Consumer Forum has no jurisdiction to entertain this case. There was no deficiency in service. Complainant has got no basis about his claim of his cost of treatment. The specific case of the O.P. no.1 Insurance Co. is that this complainant purchased health insurance policy for himself and for his family member from the O.P. no.1. accordingly, he deposited amount of premium for the first time on 18-03-2010 and thereafter, paid premium for the renewal of the said policy for the period from 18-03-2010 to 17-03-2011 and thereafter, paid premium for the renewal of the policy for the period 18-03-2012 to 17-03-2013 and for period 18-03-2012 to 17-03-2013. Payment sum of Rs. 1750/- vide cheque no.017402 dated 15-03-2013 of Bangiya Gramin Vikash Bank, Bankura branch for renewal of insurance policy to the branch of O.P. no.3 in favour of O.P. no.1 by Complainant and the fact of acknowledgement of said cheque by putting signature by the O.P. no.1 as claimed by the Complainant has been denied by the O.P. no.1. It is further stated in W.V. that Complainant had pre-existing decease and suppressing the said fact Complainant took the impugned policy. So, according to O.P. no.1 this Complaint is liable to be dismissed.
On the other hand, O.P. no.3 filed W/V but he did not take part at the time of hearing of this case ; but O.P. no.3 claimed in it’s W.V. inter-alia that he had no part / role in the matter repudiation of claim of Complainant. So, complaint will be dismissed against it.
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Point for determination.
1) Whether this Complaint is maintainable ?
2) Whether the Complainant had any valid mediclaim policy for the impugned period for
which he had made claim for realization for his medical expenses ?
3) Whether the Complainant is entitled to get any award as prayed for ?
Decision with reason.
In this case Ld. Advocate for the Complainant argued inter-alia that the Complainant initially purchased mediclaim policy from the O.P. no.1 Company for the period from 18-03-2009 to 17-03-2010 for the first time and said policy was renewed from time to time by paying premium. At the last time this Complainant paid Rs.1750/- vide Cheque No. 017402 dated for renewal of the said mediclaim policy from the period 18-03-2013 and said cheque was received by the O.P. no.1 on 16-03-2013 but this O.P. no.1 renewed the said policy for the period from 26-03-2013 to 25-03-2014 instead of 18-03-2013 to 25-03-2014 with malafide intension. This Complainant made claim for reimbursement of his medical expenses for getting treatment from the Apollo Hospital, Madras for the period 06-07-2013 to 09-07-2013 during the validity period of his mediclaim policy but this O.P. declined to pay any amount.
Ld. Counsel for the Complainant further denied pre-existing decease of Complainant as alleged by the O.P. no.1 Insurance Co.
On the other hand Ld. Counsel for the O.P. no.1 argued inter alia that this Complainant had pre existing decease and suppressing the said fact he took the mediclaim policy. So, he is not entitled to get any compensation.
Ld. Counsel for the O.P. further argued that there was no continuation / renewal of policy as alleged by Complainant. This O.P. no.1 issued a new policy for the period 26-03-2013 to 25-03-2014 and as per terms & condition of the policy this claimant is not entitled to get any claim as he treated himself during the waiting period of the impugned policy. So, according to him this Complainant is not entitled to get any relief or compensation as prayed for and this complaint is liable to be dismissed.
In support of his claim Ld. Advocate for the claimant referred 2012(4) CPR Page 494 (NC)
Branch Manager (Legal), Life Insurance Corporation of India & Anr. Versus C.P. Sinha.
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We have carefully heard the submission made by the Ld. Advocate for either side. Perused the written argument filed by both sides.
Perused the petition of complaint, W.V. and materials on record and the Xerox copies of documents. It appears to us that the genuineness of the impugned policy purchased from the O.P. no.1 Insurance Co. by the Complainant is undisputed. In this case the O.P. no.1 has alleged that there was pre-existing decease before the purchase of the impugned policy.
On the other hand said allegation has been denied by Complainant.
In this case we find that no documents have been filed on behalf of the O.P. no.1 / Insurance Company to show that the Complainant had pre-existing decease. It has observed by the Hon’ble National Commission repudiated in 2014 (3) Consumer Law Today page 49 (NC) inter-alia that Consumer Protection Act, 1986 Section 2(1)(g) that insurance claim – Pre-existing decease – Repudiation on the ground that at the time of Proposal Form filled by insured he was suffering from Blood Cancer – Held – usually, the authorized doctor of the insurance co. examined the insured, assessed the fitness and after complete satisfaction, only policy will be insured – Further, we feel that the O.P. was wrong in repudiate the claim of Complainant.
So, in view of the said observation of the Hon’ble National commission that it is the practice that the insured will be examined by the authorized doctor of the insurance co. before or at the time of filling up the Proposal Form for insurance policy. So, in view of the observation of the Hon’ble National Commission we hold that the O.P. no.1 insurance co. was wrong in repudiate the claim of the Complainant on the ground of alleged pre-existing decease of Complainant.
The next defence of the O.P. no.1 is that the impugned policy is not the continuation of the earlier policy. It reveals from the Xerox copy of the policies that this Complainant purchased mediclaim policy from the O.P. no.1 initially first time for the period 18-03-2009 to 17-03-2010 and the said policy was renewed for the second time for the period 18-03-2010 to 17-03-2011 and it was also renewed for the third time on 18-03-2011 to 17-03-2012 and it was further renewed for the period 18-03-2012 to 17-03-2013 the said fact is disputed by O.P. no.1 / Insurance Company.
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It also reveals that the impugned policy was made for the period 26-03-2013 to 25-03-2014 and this Complainant made claim for reimbursement of his mediclaim expenses for the period 06-07-2013 to 09-07-2013 of Rs.1,00,000/- (One Lac).
It reveals from the insurance policy that this Complainant purchased policy for the first time for the period 18-03-2009 to 17-03-2010 and it was renewed by paying it’s premium from time to time lastly before the impugned policy for the period 18-03-2012 to 17-03-2013. So, it is undisputed about the continuation of the policy from the period 18-03-2009 till 17-03-2013.
As per argument of the Ld. Advocate for the Complainant that this Complainant issued a cheque bearing no.017402 dated 15-03-2013 for Rs.1750/- paid to O.P. no.1 Company as premium for renewal of the policy in favour of Complainant and said cheque was received by the O.P. insurance co. on 16-03-2013 as reveals from annexure – B which is Peon Book of the Mallabhoom Gramin Bank and the signature and office seal on Peon Book of Gramin Bikash Bank has not been denied by any official of the O.P. no.1 Insurance Company. So, it is clear to us that this Complainant paid Rs.1750/- for renewal of his policy for the period 18-03-2013 to 25-03-2014 before the expiry of the period of his earlier policy renewed for the period 18-03-2012 to 17-03-2013, within time. So, it was the responsibility of the Branch Manager of O.P. no.1 to encash the said cheque and to issue proper policy for the proper period i.e. for the period 18-03-2013 to 25-03-2014 ; so we find no fault on the part of the Complainant in paying premium of the mediclaim policy for the period 18-03-2013 to 25-03-2014. But it is unfortunate that this O.P. no.1 issued a new policy for the period 26-03-2013 to 25-03-2014 despite payment of premium of the renewal of his mediclaim policy by the Complainant before expiry of the period of his earlier policy, after breaking period of his earlier policy.
It has been observed by the Hon’ble National Commission reported in 2012 (4) CPR Page 494 (NC) inter-alia that “Consumer Protection Act, 1986 – Sections 15, 17, 19 and 21 – Insurance – Repudiation of death claim – District Forum directed opposite party to pay Rs. 1 lakh to complainant along with Rs.2,000/- as costs – Cheque for first premium was received by agent of LIC and it was deposited in office of LIC – Said amount was returned after about
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2-years and 9-months – LIC has failed to give any lucid explanation as to why cheque was withheld for a period of 2 years and 9 months – LIC grants insurance cover after acceptance of money – Insurance starts the moment cheque is accepted – If there is no irregularity or facts are admitted by LIC, it cannot turn around and discard proposal after a lapse of more than two years – Revision petition dismissed”.
In view of the above observation of the Hon’ble National Commission that insurance starts at the moment cheque is accepted. In the present case reveals from annexure – B that this O.P. no.1 Insurance Co. accepted the cheque bearing no.017402 dated 15-03-2013 of Rs.1750/- paid by the Complainant for renewal of his insurance policy on 16-03-2013.
So, in view of observation of the Hon’ble National Commission that the insurance of the Complainant involved in this case has started on 16-03-2013 at the moment when the cheque bearing no.017402 dated 15-03-2013 accepted by the O.P. no.1 Insurance Company on 16-03-2013.
So, in view of the facts & circumstances we hold that the cheque as stated above was given by the Complainant before expiry of period of earlier mediclaim policy for renewal of his earlier policy and the same was accepted on 16-03-2013 by the O.P. no.1 insurance co. So it is nothing but for renewal / continuation of his earlier mediclaim policy for the period 18-03-2013 to 25-03-2014 but it was renewed / issued for the period 26-03-2013 to 25-03-2014. So, repudiation of the O.P. no.1 company in payment of the claim of the Complainant was wrong. As such, Complainant is entitled to reimbursement of his medical expenses as prayed for.
It reveals from annexure – C that the Complainant was admitted in the Apollo Hospital for his treatment on 07-07-2003 and he was discharged on 09-07-2013.
It reveals from annexure – E that the Complainant has expended Rs.1,08,369.62 for his treatment at Apollo Hospital. This matter has not been disputed. Complainant had mediclaim policy upto the limit of Rs.1,00,000/- . So, he is not entitled to get any amount of reimbursement of his medical expenses more than Rs.1,00,000/- . So, we hold that the Complainant is entitled to reimburse / get Rs.1,00,000/- along with interest from the date of filing this complaint. We also hold considering the mental agony and harassment of
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Complainant if simple interest @ 9% is awarded on Rs.1,00,000/- to meet the justice then none would be prejudiced. We also like to award to Rs.5,000/- towards cost of litigation against O.P. no.1 for meet justice to parties. We do not find any role / part of O.P. no.2 & 3 in the matter of repudiation of the mediclaim made by the Complainant. So, we do not like to award any amount against O.P. no.2 & 3 and this complaint is liable to be dismissed against O.P. no.2 & 3. In the result that Complaint succeeds against O.P. no.1 / Oriental Insurance Co.
Hence, it is
Ordered
That the Complaint Case no.120 of 2014 be and same is hereby allowed on contest against O.P. no.1; but dismissed against O.P. no.2 & 3.
O.P. no.1 Oriental Insurance Co. Ltd. is hereby directed to pay Rs.1,00,000/- to the Complainant as claimed by him for his medical expenses along with simple interest @ 9 % p.a. from the date of filing of this complaint till it’s full realization by thirty (30) days from the date of receipt copy of Judgement.
O.P. no.1 is also further directed to pay Rs.5,000/- as cost of litigation to the Complainant by thirty (30) days from the date of receipt of the copy of Judgement.
If O.P. no.1 Insurance Co. fails to pay the amount awarded above within the stipulated period as mentioned above then the Complainant is at liberty to proceed against O.P. no.1 / Oriental Insurance Company according to law.
Let a plain copy of Judgement be given to the parties free of cost.
__________________ ________________
HON’BLE PRESIDENT HON’BLE MEMBER
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