West Bengal

Birbhum

CC/84/2015

1. Binod Kumar Somani - Complainant(s)

Versus

Branch Manager,United India Ins Co Ltd - Opp.Party(s)

Pares Nath Banerjee

18 Jun 2018

ORDER

Shri Biswa Nath Konar, President.

            The case of the complainants Binod Kumar Somani and two others, in brief, is that they obtained a Medi-Claim Policy in the year 1997 being No. 031801/48/13/97/00000325 and they have been paying premium of Rs. 1 lakh and the said policy is still continuing without any break.

            It is the further case of the complainants that the petitioner No.2 Pratik Somani, who is aged about 17 years, suddenly became ill and brought to local doctor Dr. Anirban Dasgupta on 24.06.14, who after examining him advised to take him to Mission Hospital, Durgapur. He was brought to Mission Hospital and treated there but he was not fully cured.

            Thereafter he was admitted to “Sunflower Hospital, Nagpur” for his chest pain, palpitations and breathing problems and he was admitted there from 26.04.2014 to 06.09.14.

            A discharge certificate was issued by said hospital mentioning that he was suffering from Myotonic Dysprophy or Depression and he was suffering from said disease for long time.

            It is the further case of the complainants that they submitted a claim of Rs. 71415.50p before O.P No.1 Insurance Co. but they repudiated the claim by sending letter dated 16.01.2015 alleging pre-existing disease of the petitioner No.2 Pratik Somani and review prayer of the complainant was also rejected and the act of the O.P No.1 is nothing but deficiency in service.

Hence, this case for directing the O.P No.1 to pay Rs. 71415.50p. as claim amount with compensation of Rs. 25000/- for mental agony and harassment and cost of Rs. 2000/-.

The O.P No.1 United India Insurance Co. Ltd. has contested the case by filing written version denying all material allegation of the complaint contending inter alia the case is not maintainable and the complainants have no cause of action to bring this case.

It is the specific case of the O.P No.1 that the petitioner No. 2 Pratik Somani was admitted to Sunflower Hospital Nagpur on 26.08.14 and discharge from there on 29.08.2014 for treatment of Myotonic Dystrophy, sick sinus syndrome and he was further admitted on 01.09.14 and discharge on 06.09.14 for treatment of Myotonic Dystrophy and Depressive disorder.

It is the further case of the O.P No.1 that as per policy condition No. 4.6 and 4.16 the O.P Insurance Co. shall not be liable to make any payment under this policy in respect of expenses whatsoever incurred by any insured person in connection with or in respect of convalescence, general debility run down condition or rest cure obesity treatment and its complication including morbid obesity, congenital external disease or defects or anomalies, treatment relating to all psychiatric or psychometric disorders. Infertility sterility, venereal disease intentional self-injury and use of intoxication drug/alcohol and generic disorders and stem cell implication and surgery. The treatment of Myotoic Dystrophy is a genetic disorder and depressive disorder is a psychiatric disease and as such the complainants are not entitled to get any relief in this case and the case is liable to be dismissed with cost. 

Inspite of due service of notice O.P No.2 Heritage Health TPA Pvt. Ltd. has not appeared before this Forum and the case was heard ex parte against them.

Point for determination.

1.  Whether the complainant is a consumer under Sec. 2(1)(d)(ii) of the C.P. Act.?
2. Whether this Forum 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

During the trial the complainant No.1 Binod Somani has been examined as PW1 and also filed some documents. He was also cross examined by the O.P  No.1 by filing questionnaires.

One Amal Kr. Gupta, Administrative Officer, United India Insurance Co. Suri Branch has been examined as OPW 1. He also filed some document and cross examined by filing questionnaires.

 Heard argument both sides.

Point No.1:: Evidently the complainants obtained a Medi-Claim Policy in the year 1997 with a premium of Rs. 1 lakh and the same is still continuing from the O.P No. 1 United India Insurance Co. Ltd. Suri Branch.

So, the complainants are a consumer U/s 2(1)(d)(ii) of the C.P. Act.

Point No.2:: O.P No. 1 has Office within jurisdiction of this Forum.

The total valuation of the case is Rs. 98415.50p which is far less than maximum limit of the pecuniary jurisdiction of the Forum i.e. Rs. 20,00,000/-.

So, this Forum has pecuniary and territorial jurisdiction to try this case.

Point No. 3 and 4:: Both points are taken up together for convenience of discussion as they are related to each other.

The complainant No.1 Binod Kr. Somani in his complaint and evidence stated that they obtained a Medi-Claim Policy in the year 1997 being No. 031801/48/13/97/00000325 and they have been paying premium of Rs. 1 lakh and the said policy is still continuing without any break.

Copy of the policy certificate shows that Rs. 6084/- was paid as premium of the policy in question for the period 30.09.13 to 29.09.2014 for the complainant No. 2 Pratik Somani.

PW1 Binod Somani in his evidence further stated that the petitioner No.2 Pratik Somani, who is aged about 17 years, suddenly became ill and brought to local doctor Dr. Anirban Dasgupta on 24.06.14, who after examining him advised to take him to Mission Hospital, Durgapur. He was brought to Mission Hospital and treated there but he was not fully cured. Thereafter he was admitted to “Sunflower Hospital, Nagpur” for his chest pain, palpitations and breathing problems and he was admitted there from 26.04.2014 to 06.09.14. A discharge certificate was issued by said hospital mentioning that he was suffering from Myotonic Dysprophy or Depression and he was suffering from said disease for long time.

Copy of treatment sheet/prescription/discharge card issued by Dr. Anirban Dasgupta, Mission Hospital, Durgapur, Apollo Hospital Kolkata and Sunflower Hospital Nagpur show that the complainant No. 2 Pratik Soamani was treated by said doctor/hospitals.

PW.1 Binod Somani further stated that they submitted a claim of Rs. 71415.50p before O.P No.1 Insurance Co. but they repudiated the claim by sending letter dated 16.01.2015 alleging pre-existing disease of the petitioner No.2 Pratik Somani and review prayer of the complainant was also rejected and the act of the O.P No.1 is nothing but deficiency in service.

Copy of the claim application shows that claim of Rs. 71415.5p. was submitted by the complainant before the O.P No.1 Insurance Co.

Copy of the letter dated 30.10.14 shows that by sending said letter the claim of the complainant was repudiated on the ground that the patient was admitted for the treatment of Myotonic Dysprophy which is a genetic disorder. Second hospitalization was does due to Depressive disorder which is a psychotic disease and as per terms and condition of the policy said diseased are excluded from the policy by clause No. 4.6 and 4.14.

We find from the copy of ENG report issued by Dr. Ketan Chaturbedi regarding the patient Pratik Somani that he opined that this ENG study is suggestive of Myotonic Dysprophy.

Discharge card dated 26.08.14 and 01.09.14 show that Pratik was admitted on 26.08.2014 at Sunflower Hospital, Nagpur and discharge from there on 29.08.14 for treatment of Myotonic Dysprophy Sick Sinus Syndrome and he was further admitted on 01.09.14 and discharge on 06.09.14 in the said hospital for treatment of Myotonic Dysprophy, Sick Sinus Syndrome and depressive disorder.

We further find as per Google Search Myotonic Dysprophy is a long terms genetic disorder that effect muscle function.

We find from clause 4.6 of terms and conditions of the policy that all treatment relating to psychiatric and psychiatric disorder are excluded from the policy. The clause 4.14 of terms and conditions of policy also shows that treatment relating Genetic disorders & stem cell implantation / Surgery are also excluded from the policy.

So, considering over all matter into consideration and evidence on record we are constrained to hold that ailments of complainant No.2 Pratik Somani do not come under the purview of the policy in question.

So, the complainants are not entitled to get any relief in this case.

Accordingly both these points are decided against the complainants. Case fails.

Proper fees have been paid.

Hence,

O R D E R E D

that C.F case No. 84/2015 be and the same is dismissed on contest against the O.P No.1 and ex parte against the O.P No.2 without any order as to cost.

             Copy of this order be supplied to the parties each free of cost.