West Bengal

Birbhum

CC/134/2023

Aparesh Mondal - Complainant(s)

Versus

Branch Manager The Star Health Insurance Company - Opp.Party(s)

Sanjit Kr Acharya

31 Jul 2024

ORDER

Shri Sudip Majumder  President in Charge.

            The complainant/petitioner files this case U/S 35 of Consumer Protection Act, 2019. The fact of the case in brief is that the petitioner/complainant, Aparesh Mondal by occupation Assistant Professor at Swarnamoyee Jogendranath Mahavidyalaya, Purba Medinipur, resident of Vidyasagarpally,Nichupally, P.O. and P.S.-Bolpur, Dist. Birbhum. The petitioner purchased medical insurance policy [Young Star Insurance Policy (Floater)] vide policy No. 11230043980900 by paying proper premium of Rs. 8,513/- for himself and his spouse. The said policy was valid from 07/06/2022 to midnight of 06/06/2023. Thereafter, the policy was renewed on 07/06/2023 vide renewal No. 11230043980901 and thus, the policy is valid upto midnight of 06/06/2024.

            It is the case of the complainant that on August 13,2022 the complainant sustained severe injury due to a fall from train at Howrah station and in consequence thereof, his left leg was twisted and he got severe ligament injury on knee. That on the following day the complainant consulted with Dr. Rudra Sinha at Bolpur and his treatment was started under the supervision of Dr. Sinha. That after prolong treatment for 9 months as the injury was no cured, the complainant got admission at Apollo Chennai for better treatment of ligament injury in the left knee under Dr. Krishnamoortthy K (ortho). That the doctor diagnosed the complainant with left knee Anterior cruciate Ligament Reconstruction with Medical Meniscal Repair and in that respect surgery was done accordingly.

           

(Page 1 of 5)

 

 

 

 

 

It is the further case of the complainant that  being the aforementioned Mediclaim insurance policy holder before getting admission in Apollo Hospital the complainant claimed for costless treatment under the Star Health Insurance (opposite party) but the OP insurance company declined and asked for reimbursement the claim of the complainant. That the complainant incurred expenses of Rs. 2,99,854/- against his aforementioned treatment before the Apollo Hospital Chennai.

            It is the next case of the complainant that after completion of treatment Apollo Hospital Chennai the complainant submitted all the necessary documents before the OP for the reimbursement of his claim which was denied by the OP initially. That the OP insurance company did not consider the claim of the complainant and they repudiated the claim of the complainant through their letter dated 24/07/2023 on the ground of preexisting and non-disclosure of material facts arbitrary and illegally.

            It is the specific case of the complainant that the complainant got injury on August 13, 2022 and he was treated by the doctor on 14/08/2022 i.e. on the following day of accident and there after he could not attend the college since 16/08/2022 to 28/08/2022. Be it mentioned here 14/08/2022 and 15/08/2022 was holiday as both days are Sunday and Independence Day respectively. That the aforesaid incident will prove the incident and it will be cleared that the complainant did not suppress any material facts.

            Hence, after finding no other alternative the complainant is compelled to file this complaint before this Forum/Commission for proper relief and prays for order to:-

“(a) To pass an order direction the opposite party to pay Rs. 2,99,854/- to the complainant to reimburse the medical expenses incurred by him.

(b)To pass an order direction the opposite party to pay interest @12% p.a. on Rs. 2,99,854/- since 01/06/2023 till realization of claim.

(c)To pass an order direction the opposite party to pay Rs. 1,00,000/- as compensation for causing mental agony and harassment.

(d)To pass an order direction the opposite party to pay Rs. 20,000/- as litigation cost.

(e)Other relief/reliefs.”

It appears from case record that the OP insurance company did not appear before this Commission after receiving the notice. None appears and no step is taken by the OP insurance company. No written version has yet been filed by both the OP insurance company. As a result, vide order No. 05 dated 15/01/2024 this Commission ordered for run the instant case exparte against both the OP insurance company.

 

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Complainant’s side submitted evidence-in-chief and written notes on argument. Some documents have also been filed by the complainant. Those have been compared with original documents. Thereafter, Ld. Advocate for the complainant made oral argument in support of his case.

Points for determination/Issues

1) Whether the complainant is a consumer as per definition of the term ‘Consumer’ of the C.P Act. ?

2)Whether this Commission has jurisdiction to try this case?

3)Whether there is any deficiency in service on the part of the O.Ps?

4)Whether the complainant is entitled to get any other relief or reliefs as prayed for?

Decision with reasons

Point No. 1:

            In this case, the petitioner purchased medical insurance policy [Young Star Insurance Policy (Floater)] vide policy No. 11230043980900 by paying proper premium of Rs. 8,513/- for himself and his spouse. Hence, the complainant is a consumer under the OP insurance company as per Sec. 2 (7)(ii) of the Consumer Protection Act, 2019 and the OP insurance company is the service provider.

Point No. 2:

            In this case, the cause of action arose from 24/07/2023. The case has been filed on 17/10/2023 and as such it can be said that the complainant has filed this case within the statutory period of the C.P. Act, 2019 and as such the instant complaint is not barred U/S 69(1) of the C.P. Act, 2019.

Pecuniary Jurisdiction of this District Commission as per Notification No. G.S.R. 892(E). dated 20^th December, 2022 by Consumer Affairs Department, Govt. of India, New Delhi i.e. Rs. 50 lakh.

The complainant is a resident of Vidyasagarpally, Nichupally, P.O. and P.S.-Bolpur, Dist. Birbhum, which is under the Territorial Jurisdiction of this District Commission as per Sec. 34(2) of C.P. Act, 2019.

               Hence, this Commission has Pecuniary Jurisdiction as well as Territorial Jurisdiction on the present issue.

Point No. 3:

It appears from the documentary evidence as available in the case record that the complainant admitted before Apollo Hospital, Chennai on 31/05/2023 and surgery at LEFT KNEE ARTHROSCOPIC ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION WITH MEDIAL MENISCAL REPAIR (IMPLANTSIRONIX). Done by Dr. Krishnamoorthy K (ortho), D.Ortho, DNB, Orthopaedics. Regn. No. 46844 (Tamil Nadu). The complainant discharged from the said hospital on 02/06/2023. The complainant incurred Rs. 299,584/- for the cost of the said treatment. The sum assured of the said insurance policy was Rs. 5,00,000/- (floater). The said treatment also done within the validity of the said insurance policy.

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The OP insurance company repudiate the claim of the complainant through a letter vide dated     20-07-2023 and stated that “It is observed from the documents and information available with us that the insured patient has sustained injury on May 2022 which confirms that the insured patient has above injury prior to inception of medical insurance policy. The present admission and treatment of the insured patient is for non-disclosed disease.

            At the time of inception of your policy which is from 07/06/2022 to 06/06/2023, you have not disclosed the above mentioned medical history/health details of the insured-person in the proposal form which amounts to misrepresentation/non-disclosure of material facts. Had you disclosed the above preexisting disease/s in the proposal form we would not have issued the policy.

As per Condition No. 1, of the policy issued to you, if there is any misrepresentation/non-disclosure of material facts whether by the insured person or any other person acting on his behalf, the Company is not liable to make any payment in respect of any claim.”

            Our observation:

                        As per the version of the complainant that he sustained severe injury due to fall from train at Howrah station on 13/08/2022. But, the OP insurance company stated in their repudiation letter that the insured patient has sustained injury on May 2022. It is very curious to us that how did the OP insurance company know that the injury occurred in May, 2022. The OP insurance company could not produce any documents in this regard. Therefore, it appears to us, that the cause shown for repudiation of said claim by the OP insurance company is vexatious one. Necessary question may also come as to why the said OP/Insurance Company did not verify the health condition of the complainant before entering him in the insurance policy. But, after taking the complainant as an insured, the OP is estopped from raising any further/objection on his policy coverage when the claim his made after treatment, depending on reimbursement from such policy.

Moreover, after receiving the notice the OP insurance company did not appear and contest this case.

Thus the OP insurance company appears to have admitted the fact. It is proved beyond all reasonable doubt that there is/was deficiency in service as per Sec. 2(11) of the C.P. Act, 2019. Moreover it is a pointer of unfair trade practice as per   Sec. 2(47) of C.P. Act, 2019 on the part of the OP insurance company.

Hence, from the above discussion it is proved that the complainant has able to prove his case beyond all reasonable doubt.

 

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Point No. 4:

As in this case, it is proved that there is deficiency in service on the part of the OP insurance company.

Hence, the complainant is entitled to get relief or compensation as prayed for.

Thus, all the points are decided in favour of the complainant.

Complaint is sufficiently stamped and proved beyond all reasonable doubts.

Hence, it is,

O R D E R E D,

                           that the instant C.C. Case No. 134/2023 be and same is allowed exparte

with cost.

The OP insurance company is directed to pay Rs. 2,99,854/- (Two lakh ninety nine thousand eight hundred fifty four only) to the complainant to reimburse the medical expenses incurred by him.

The OP insurance company is also directed to pay Rs. 10,000/-(Ten thousand only) as compensation for mental agony and harassment to the complainant/petitioner and also to pay Rs. 5000/- (Five thousand only) as cost of litigation to the complainant.

The entire decree will be complied by the OP insurance company within 45 (Forty five) days

from this date of order, failing which entire amount shall carry interest @ 9% p.a. till its realization.

If the OP insurance company failed to comply the decree the complainant would be at liberty to

put this order to execution in accordance with law.

The instant case is thus disposed of.

Let a copy of this order be given/handed over to the parties to this case free of cost.