Judgment : Dt.20.2.2017
This is a complaint made by one Sisir Kumar Basak, Advocate, residing at 6, Maharaja Tagore Road (Ground floor), Kolkata-700 031, P.S.- Lake P.S. near Babu Bagan against (1) Chief Manager, HDFC Standard Life Insurance Co. Ltd. 26A, 1st floor, Gariahat Shopping Mall, Gariahat, P.S.-Gariahat, Kolkata-700 029, OP No.1, (2) Chief Grievance Redressal Officer, HDFC Standard Life Insurance Co. Ltd., 12th & 13th floor, Lodha Apollo Mill Compound, N.M. Joshi Road, Mahalaxmi, Mumbai-400011, OP No.2, (3) Dr. Ravikant Sapaia, authorised signagory, E-Meditek (TPA) Services Ltd., Plot No.5771, Udyoyvihar, Phase-V, Gurgaon, Haryana-122 016, OP No.3, (4) Managing Director, HDFC Standard Life Insurance Co. Ltd. Lodha Excelus,s 13th floor, Apollo Milla Compound, N. M. Joshi Marg Mahalaxmi, Mumbai-400 011, OP No.4 and (5) Managing Director, HDFC Standard Life Insurance Co. Ltd., 1st floor, 165-166, Backbay Reclamation, H.T. Parekh Marg, Churchgate, Mumbai-400 020, OP No.5, praying for reimbursement the hospitalization claim against Insurance Policy No.90002676 to the Complainant, interest @ 16%p.a. and damages to the tune of Rs.15,00,000/- and litigation cost to the extent of Rs.20,000/-.
Facts in brief are that Complainant is a Health Insurance policy holder vide No.90002676 of HDFC Standard Life Insurance Policy Ltd. The said policy was issued on 5.6.2013 by endorsement of the Complainant’s proposal dt.11.5.2013. Complainant disclosed in detail and declared each and every of his previous diseases to the Financial Planning Manager of the HDFC Standard Life Insurance Co. Ltd. The premium amount was Rs.9,706/- p.a. But, after verification this amount was fixed to Rs.12,133/-.
Complainant was hospitalized on 25.3.2015 at AMRI hospital due to attack of Left Subacute Subdural Hematoma and was discharged don 7.4.2015. But , claim of hospitalization was made, Complainant sent cash less request for the treatment. But it was refused on the ground its non-disclosure of previous disease. Aggrieved by that Complainant wrote a letter to the HDFC Standard Life Insurance Co. Ltd. Hospitalisation claim of Rs.2,05,095/- has not been paid to it. As per section 45 para 22 of Insurance Act, this grant is not applicable. Complainant got operated of stomach cancer in 1992 i.e. 23 years ago and now he is completely alright. Further, Complainant has stated that there are decisions that on this ground claim cannot be repudiated.
OP No.1, 2, 4 & 5 filed written version and denied all the allegations of the complaint. Further, they have stated that in or about May, 2013, OP received a duly filled up and signed proposal form for purchasing a Health Insurance Policy and the medi-claim insurance policy was issued in favour of the Complainant. The premium was Rs.12,133/-. Thereafter, on 26.3.2015 Complainant made a claim. Thereafter, TPA carried an investigation and it was discovered that the Complainant was suffering from hyper-tension. The Complainant misrepresented and did not make full disclosure. So, the claim of the Complainant was repudiated. As such, this OPs prayed for dismissal of this case.
Decision with reasons:
Complainant filed affidavit-in-chief wherein he has reiterated the fact he has made out in the complaint petition and against this the OP No.1, 2, 4 & 5 filed questionnaire to which Complainant replied. Similarly, OPs filed evidence against which the Complainant filed questionnaire and the OPs replied.
Main point for determination as to whether the Complainant is entitled to the reliefs.
On perusal of the complaint, it appears that the Complainant has prayed for reimbursement of the amount which he spent for his treatment. Original document of the insurance policy has been filed which reveals that Complainant paid the premium of Rs.12,133/-. Further, Complainant has filed documents in order to establish that he was under treatment of AMRI hospital and he spent Rs.2,05,095/-. Further, it appears that documents establish that Complainant made the expenditure and he was not reimbursed by the Insurance Company. Despite having this mediclaim insurance company, the claim was repudiated on the ground of pre-existing diseases. Ld. Advocate for Complainant submitted that his client had undergone a surgical operation for stomach cancer before 23 years and the repudiation was made on that ground. It also appears that the TPA came to the finding that Complainant used to suffer from hyper-tension due to which he suffered injury. So, the claim was repudiated.
In our views, this hyper-tension cannot be a ground for repudiation of the claim of the insurer because at some point of time or other almost all individual suffer from hyper-tension. Further, it is clear that the expenditure made by the Complainant at AMRI was to the tune of Rs.2,05,000/-. Ld. Advocate for Complainant submitted certain decisions wherein it has been clearly stated that a pre-existing disease cannot be a ground for repudiating the claim after 3 years of purchase of policy.
As such, we are of the view that such repudiation by the OP has not been done in accordance with law and, therefore, the OPs are bound to reimburse the claim of the insurer as prayed.
At this stage, it is made clear that Ld. Advocate for Complainant submitted with original prescription, but, vouchers are lying with the OP and so there is no need of passing an order for filing or producing original vouchers.
Complainant has prayed for compensation of Rs.15,00,000/- which is excessive. However, in the circumstances, if compensation of Rs.15,000/- and litigation cost of Rs.10,000/- are allowed, the object of justice would be served.
Hence,
ordered
CC/84/2016 is allowed on contest. OPs are directed to reimburse the expenditure made by the Complainant during his treatment at AMRI. The OPs are also directed to pay to the tune of Rs.2,00,000/- on the basis of vouchers, receipts and prescriptions. In addition, OPs are directed to pay Rs.25,000/- as compensation and litigation cost within two months of this order, in default the amount shall carry interest @ 12%p.a. till realization.
