FINAL ORDER/JUDGMENT   

SMT. SUKLA SENGUPTA, PRESIDENT

This is an application filed by the complainant U/s 13 of the CP Act 1986 against the OP Cholamandalam, M/s General Insurance Company Ltd. The OP is running its business within the jurisdiction of this forum.

The fact of the case in brief is that the complainant being a senior citizen is a member of Cholamandalam, M/s General Insurance Company Ltd. vide Health Policy No. 2842/00139999/001/000/00. The membership No. is A 3964819A. The total sum assured was of Rs . 3,00,000/-  (Rupees  three lacs) only. The policy started from 22.11.2017.

It is the further case of the complainant that suddenly petitioner was fallen ill  and was admitted  to the C K Birla Hospital on 06.07.2018 and discharged on 11. 07.2018. After clinical examination,  the report of blood presser of the complainant was 130/70, cardio vascular system and other system are normal and also echo cardiogram level shown 45 %. 

The complainant further stated that in the past history,  the complainant was normal in health and there was no head injury as well as no hypertension.  As per the complainant’s case he was discharged from C K Birla hospital on  11.07.2018 and the bill was (hospital charge) of Rs. 89,153/- only which was placed before the OP Insurance Company but unfortunately, the OP Insurance Company refused the claim. The complainant submitted all the required documents and the doctors report before the Insurance Company for getting claim in spite of the same the OP Insurance Company repudiated  the claim .

Under such circumstances without having any other alternative,  the complainant has filed the case with a prayer to give direction to the OP Insurance Company  to release the medical claim amount of Rs. 89,153/- only with interest up to date in favour of the complainant.

The OP Insurance Company has  contested the claim application by filing WV  through its manager the authorised representative and  signatory Mr. Deborashi Bhowmik.

The OP denied all the material allegations leveled against it and also challenged  the maintainability  of this case.

It is the further case of the OP that the petition of complaint is harassive, malafide and sculptive . The complainant  has got no cause of action to file the case as well as the petition of complaint as barred by limitation.

The OP stated that the complainant is not a consumer within the ambit of CP Act 1986. and the petition of complaint is bad for necessary  parties.  Admittedly, the policy in question   is an insurance policy No. 2842/00139999/001/000/00 for the period of 22.11.2017 to 21.11.2018 (exhibit- 1).

The sum assured of the policy  is Rs. 3,00,000/-.  It is also admitted fact that during the subsistence  of the policy,  the complainant was admitted in CK Birla Hospital on 06.07.2018 with complaint of acute onset of restrosternal chest pain since 3.00 pm of  05.07.2018 associated with profoue sweating , nausea and mild shortness breath. The complainant was discharged from 11.07.2018 . It is alleged by the OP Insurance Company that as per discharge summary,  the complainant was suffering from hyper tension as reflected from  past medical history (exhibit-1A).

            It is alleged by the OP Insurance Company that the complainant has suppressed the pre- existing disease of hyper tension. So, the claim is not payable because of  non -disclosure of material facts regarding pre-existing disease of the complainant and at the time of issuance of policy  and thus, the claim has been repudiated by the OP Insurance Company.

It is alleged by the OP Insurance Company that the petition of complaint is baseless unreasonable and not tenable in the eye of law and thus, the same  is liable to be dismissed with exemplary cost.

In view of the above stated facts and circumstances, the points of consideration are as follows:-

1. Is the case maintainable within the ambit of law?

2. Is complainant a consumer?

3. Has the complainant cause of action to file this case?

4. Is there any deficiency in service on the part of the OP?

5. Is the complainant entitled to get relief as prayed for?

Decision with reasons

All the points of considerations are taken up together for convenience of discussions and to avoid unnecessary repetitions.

            On careful perusal of the materials on record and considering the position of law, it appears that the case is well maintainable in the eye of law and this forum has got ample jurisdiction both territorial and pecuniary to try this case.

            Admittedly, the complainant purchased one health insurance policy in the year  2017 from the OP Insurance Company and the policy being No. 2842/001/39999/001/000/00 and having membership No. 3964819A, being a part of matter policy issued to M/s Oriental Bank of Commerce. From which it is crystal clear that admittedly, the complainant is a consumer and the OP Cholamandalam M/s General Insurance Company Ltd. is the service provider. The policy in question was issued by the OP Insurance Company for a period of 22.11.2017 to 21.11.2018 and the sum assured of the health policy in question of the complainant was of Rs. 3,00,000/- only.

Now let us see whether there was any sort of deficiency in service on the part of the OP

Insurance Company of this case or not.

            It is the complainant’s case  that  on 06.07.2018 due to sudden mild chest pain he was advised by doctor to take admission in C K Birla Hospital, National Library Avenue, Kolkata-700027 under the supervision of doctor Biman  Kahali renowned cardiologist. During his stay at the above mentioned hospital, some test and check up were done namely eco cardio gram and found that the eco-cardiogram, cardiovascular gram and blood pressure of the complainant were normal and ultimately, he was discharged from the hospital on 11.07.2018. The hospital charge was of Rs.  89,153/- only. The said amount was of Rs.  89,153/- paid by the complainant. then the complainant informed the hospital authority regarding his health insurance policy and requested them to claim the amount of OP Insurance Company but the insurance company vehemently and deliberately  denied and refused the claim on the ground of suppression of previous disease of hypertension which compelled the complainant to pay the entire medical bill of  Rs. 89,153/- to C K Birla Hospital Authority at his own accord. Thereafter, on so many occasion the complainant requested  the OP Insurance Company to settle the claim of Rs.  89,153/- in his favour out of his health policy in question. But the OP Insurance Company did not pay any heed to his request and the OP Insurance Company  harassed the complainant . The OP Insurance Company took the plea that at the time of getting the policy in question,  the complainant did not disclose the matter of hyper tension from which he was suffering since long back. Ld. Advocate for the complainant in this regard has argued in BNA as well as his oral argument that it is/was the duty of the OP Insurance Company to check up the health of the policy holder prior to issue the policy by its own doctors panel and being satisfied the health condition of the policy holder,  they issued the policy. So, it is the gross negligence on the part of the insurance company that they did not make any health check up by its own doctors panel prior to issue  the policy to the complainant /insured. Once the policy issued in favour of the complainant the OP is stopped from raising any question  regarding  pre-existing decree like hypertension. Moreover, the complainant had no issue of hypertension at that time. 

On the other hand, in so many cases it is observed by the Hon’ble Apex Court that hyper tension is not disease and it can be controlled by taking medicine time to time. So, if the claim of the policy holder   is genuine then it cannot be  denied by the OP  Insurance Company only on the ground of hyper tension. Relying upon the view of Hon’ble the Apex Court,  this forum is also opined that it was the duty of the OP Insurance Company to check up the health condition of the complainant by its own doctors panel prior to issue the health policy in his favour of the complainant  but after issuing the same, the OP Insurance Company cannot deny  the claim of  the complainant only on the ground of suppression of pre-existing disease like hyper tension. By such conduct the OP Insurance Company harassed the complainant and denied the genuine claim  of the complainant which cannot be done by them.

 This forum is of opinion that the complainant is a genuine policy holder and the OP is the service provider. As per advice of attending doctor, the complainant admitted at the hospital C K Birla Hospital on 06.07.2018 and was discharged there from on 11.07.2018. The hospital bill was of Rs.  86,153/- only. The complainant rightly placed the claim before the OP Insurance Company but that has been arbiterally and in humanic way refused by the OP Insurance company which cannot be done. The claim of the complainant is genuine one. So, being a consumer as per CP Act, 1986 the complainant is entitled  to get health  claim of Rs.  89,153/- from OP Insurance Company. The OP Insurance Company is bound to pay the amount to the complainant but it denied the same whimsically  which compelled the complainant to knock  the door of this forum for getting the remedy.

Under such circumstances and considering the fact and circumstances as well as evidence on record, this forum is of view that such conduct of the OP is amounting to deficiency  in service  for which the OP Insurance Company is liable to pay compensation  for harassment,  mental  pain  and agony.

On the basis of discussion made above, this forum is of view that being  a consumer the complainant could be able to prove his case beyond all reasonable doubt and is entitled to get relief  as prayed for.

All the points are considered and decided favorably to the complainant. 

The case is properly stamped.

Hence,

Ordered

that the case be and the same is decreed on contest with cost of Rs.  5,000/- against  the OP cholamandalam M/s General Insurance Company Ltd.

The complainant do get the decree as prayed for.

The OP cholamandalam M/s General Insurance Company Ltd.  is directed to pay a sum of Rs.  89,153/- to the complainant with interest @ 6 % p.a. on the amount stated above from the date of filing of this case till realisation within 45 days from this date of order.

Copy of the judgment be uploaded forthwith on the website of the commission for perusal.