West Bengal

Bankura

CC/40/2019

Angur Mondal - Complainant(s)

Versus

Branch Manager, The Oriental Insurance Company Ltd - Opp.Party(s)

Jayanta Kumar Mukharjee

11 Dec 2023

ORDER

IN    THE   DISTRICT   CONSUMER   DISPUTES   REDRESSAL COMMISSION, BANKURA

  Consumer Complaint No. 40/2019

         Date of Filing: 19-07-2019

Before:                                        

1. Samiran Dutta                            Ld. President.      

2. Siddhartha Sankar Bhui            Ld. Member.                            

 

For the Complainant:  Ld. Advocate Jayanta Kr. Mukhopadhyay

For the O.P.: Ld. Advocate Chandicharan Adhvaryyu

                                                                                                                                                                    

Complainant

Angur Mondal, W/O Late Lakshman Mondal @ Lakshman Chandra Mondal, Resident of Chandmaridanga, Math Para, Bankura, P.O., P.S. & District Bankura, Pin – 722101.

Opposite Party                                                                                                                                                                                                                                            

1. Branch Manager, The Oriental Insurance Company Ltd., BCA Building, Court Compound, District Burdwan, Pin – 713101.

2. Branch Manager, Punjab National Bank, Bankura Branch, Machantala, Bankura, P.O., P.S. & District Bankura, Pin – 722101.

3. M/s Medi Assist Insurance TPA Pvt. Ltd., 4, 4^th Floor, Premier Court, Chandni Chawk Street, Kolkata – 700072.                                                                                                                                                                                                                                                                                                   

FINAL ORDER / JUDGEMENT  

Order No.33

Dated:11-12-2023

Both parties file hazira through advocate.

The case is fixed for argument.

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

The Complainant’s case is that her husband since deceased had a Health Insurance Policy with O.P. No.1/Insurance Co. having tied up with O.P. No.2/PNB, Policy No. being 313102/48/2017/1310 for the period from 29/07/2016 to 28/07/2017 and renewed for the period from 29/07/2017 to 28/07/2018 and again renewed from 29/07/2018 to 28/07/2019 with the coverage of risks of his spouse i.e. the Complainant at the sum assured Rs.5 Lakh. O.P.No.3 is the TPA. On 18/06/2018 the husband of the Complainant Late Lakshman Mondal felt pain in abdomen and he was taken to Mission Hospital, Durgapur as outpatient and after investigation and examination he was admitted on 22/06/2018 as per advice of the treating Doctor and he remained hospitalized from 22/06/2018 to 24/06/2018 and discharged on 25/06/2018 from the said hospital. Medical expenses to the tune of Rs.1,04,758/- has been incurred at Durgapur Mission Hospital. Thereafter the husband of the Complainant got admitted at Peerless Hospital, Calcutta on 25/06/2018 and remained hospitalized till 14/07/2018 where he incurred medical expenses to the tune of Rs.4,38,815/-. Thereafter he got admitted at Asian Institute of Gastro Enterology, Hyderabad on 21/08/2018 and remained hospitalized till 05/09/2018 but unfortunately he expired on 06/09/2018 and for the aforesaid period medical expenses for Rs.2,28,667/- has been incurred at Hyderabad. The Complainant preferred claim application with the O.P./Insurance Co. for the entire medical expenses totaling Rs.7,72,240/- but the same was repudiated on the ground of pre-existing disease. The Complainant has therefore approached this Commission for appropriate relief.

                                                                                                                                                                                        Contd……p/2

                                                                                                  Page: 2

O. P./Insurance Co. contested the case by filing a written version contending inter alia that in 2013 the Complainant’s husband had similar abdominal pain before the commencement of the Insurance Policy and by suppression of that material fact he purchased Insurance Policy with the O.P. No.1 and as such the Complainant is not entitled to get any relief in this case.

.                                                                                   -: Decision with reasons: -

Having regard to the facts of the case, submission, contention and documents on both sides the Commission finds that the Complainant’s husband was previously insured with the O.P. No.1 since 2016 and he received Rs.5 Lakh as sum assured on 10/07/2017 from O.P. No.1 as Insurance claim for medical treatment of the same disease as presently detected in this case.

Ld. Advocate for the Insurance Co. has submitted before the Commission relying on the history sheet issued by the Peerless Hospital to the effect that the Complainant’s husband had been suffering from abdominal pain since 2013 and once he has received the claim for sum assured Rs.5 Lakh he cannot get further Insurance claim on the treatment of the same disease.

Ld. Advocate for the Complainant has referred to a decision of the Supreme Court dated: 04/07/2023 in Civil Appeal No.2769/2770 of 2023 where it has been held that once the Insurance Co. has accepted that concealment of a disease at the time of purchasing the Policy was not material as it was not related to the disease that caused death it cannot latter refuse further claims or renewal of Insurance Policy on the same ground. It is a common feature of the Insurance law that some diseases are recurring and there is no legal bar to get the Insurance claim at each stage of treatment for such recurring disease. In this case though the Complainant’s husband has already received Insurance claim of Rs.5 Lakh in 2017 it will not stand as a legal bar to get the Insurance claim for treatment of the same disease recurring subsequently. In this case though the disease which the victim patient was suffering was pre-existing but once the claim was accepted earlier for treatment of such pre-existing disease it has now become an existing disease covered under the policy and the O.P. No.1/Insurance Co. is bound to reimburse the medical expenses for treatment of such existing disease.

                                                                                                                                                                                          Contd……p/3

                                                                                                  Page: 3

Considering the above position of law and facts of the case the Complainant is entitled to get Rs.5 Lakh at best as the sum assured for the Policy periods under reference which the O.P. No.1/Insurance Co. must reimburse.

Hence it is ordered……..

That the case be and the same is allowed in part on contest but without cost.

O.P. No.1/Insurance Co. is directed to pay to the Complainant Rs.5 Lakh as the Insurance claim for reimbursement of medical expenses within one month from this date in default law will take its own course.

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

 ____________________                _________________         

HON’BLE   PRESIDENT          HON’BLE MEMBER