BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM
CACHAR :: SILCHAR
Con. Case No. 10 of 2014
Sri Priyabrata Goswami, ……………………………………………….. Complainant.
-V/S-
1. The United India Insurance Co. Ltd.,
Represented by its Director,
Head Office: 24 Whites Road, Chennai- 600014. O.P No.1.
2. The Regional Manager,
The United India Insurance Co. Ltd.,
Regional Office at G.S. Road, Dispur, Guwahati-781005. O.P No.2.
3. The Manager,
The United India Insurance Co. Ltd.,
S.P. Road, Shillong Patty, Silchar-788001. O.P No.3.
4. M/S Medi Assit India Pvt. Ltd.,
53-A-Rafi Ahmed Kidwai Road,
1st Floor (BATA More), Kolkata- 700016. O.P No.4.
Present: - Sri Bishnu Debnath, President,
District Consumer Forum,
Cachar, Silchar.
Mrs. Chandana Purkayastha, Member,
District Consumer Forum,
Cachar, Silchar.
Shri Kamal Kumar Sarda, Member,
District Consumer Forum,
Cachar, Silchar.
Appeared :- Rashidul Haque Laskar, Advocate for the complainant.
Jagathjyoti Paul, Advocate for the O.P. Nos.1, 2, 3 & 4.
Date of Evidence……………………….. 13-02-2015, 22-07-2015,
Date of written argument……………… 20-04-2017
Date of oral argument………………….. 25-07-2017
Date of judgment………………………. 05-08-2017
JUDGMENT AND ORDER
Sri Bishnu Debnath,
- The complaint filed by the insured Sri Priyabrata Goswami against United India Insurance Co. Ltd. and its Officer including agent M/S Medi Assit India Pvt. Ltd., under the provision of Consumer Protection Act 1986 for award of Rs.36,010/- (Thirty Thousand and Ten ) only including reimbursement of Medical bill of Rs.26,010/- (Twenty Six Thousand and Ten) only because the Insurance company repudiated his mediclaim in connection with Meclaim Insurance Policy No. 130500/48/11/97/00000946.
- He stated the fact as below:-
He purchased Mediclaim Insurance Policy No. 130500/48/11/97/00000946 from United Insurance Co. Ltd., Silchar Division. The period of insurance coverage was from 19-03-2012 to mid-night on 18-03-2013. It covers the risk of 2 (Two) persons ailments in the family of the complainant.
- Due to sudden abdomen pain of his wife Indrani Goswami, she was hospitalized on 23-04-2012 at Kee Cee Nurshing Home, Silchar and underwent Hernia operation as per advice of doctor. The matter was informed to the Insurance Company by the Complainant one day earlier to the date of admission to the hospital. However, he paid treatment expenditure including doctors charge, operation charge and cabin charge of Rs.26,010.75 Paisa and subsequently submitted the claim. Form to the United Insurance Co. Ltd., Silchar Division. But the claim has been repudiated.
- O.P United India Insurance Co. Ltd., and its Officer i.e. O.P No.1,2 and 3 in their joint W/S stated inter-alia that the ailment from Hernia was pre-existence from the date of purchasing insurance policy and it is not covered under insurance terms and conditions vide Para No. 4 clause 4.3 of the Policy document. However, the O.P further stated that in that aspect as whether ailment was pre-existing from the date of opening the Insurance Policy, the complainant was asked to produce the site of incisional Hernia and past surgical history detail with date certified by treating doctor but the complainant did not submit those documents for which claim was closed.
- During hearing the complainant deposed on oath and exhibited Insurance Policy, claim Form, Medical certificate, letter regarding post operational paper addressed to O.P No.3 etc. The O.P No.3 also examined Sri Shibabrata Bhattaacharjee, the Divisional Manager as D.W-1 and annexed copy of Insurance Policy.
- Perused written argument of both the parties engaged lawyers and evidence on record.
- In view of evidence on record the wife of the complainant underwent hernia operation at Kee Cee Nursing Home on 24-03-2012 and accordingly doctor issued Certificate. The said certificate issued by Dr. B.B. Purkayastha on behalf of Kee Cee Clinic and Nurshing Home on 06-03-2013. The certificate is attached with the claim Form vide Ext. 5. The claimant also exhibited the Mediclaim Insurance Policy and the O.P annexed the Xerox copy. The D.W-1 in his deposition stated that as per terms and conditions of Insurance Policy vide Para 4.3 in Annexure-A (i.e. on Ext.1) it is written that during 2 (Two) years of operation of the policy the expenses on treatment of Hernia are not payable. Which means that if the policy continued by way of renew and at the date of operation of Hernia of wife of the complainant the policy continue more than 2(Two) years then the Insurance Company is liable to pay expenditure of treatment of Hernia.
- In the instant case the complainant purchased Insurance Policy by payment of premium of Rs.5,030/- on 09-03-2012 and policy opened on from 19-03-2012 to Mid-night on 18-03-2013 for one year. Whether the policy of insurance renewed to the above mentioned one year from previous one year or more than one year is not clear from the evidence on record. Rather the complainant in his deposition very equivocally deposed that the Ext.1 Insurance policy at the initial stage covering the period of one year from 19-03-2012 to midnight 18-03-2013 on payment of premium of Rs.5,030/- vide Ext.2.
- Thus, it is concluded that on the date on which the Hernia treatment was done, the Insurance Policy was for less than one year from the date of opening. Hence, as per terms and conditions of Insurance Policy the complainant is not entitled to reimbursement of medical expenditure of his wife for Hernia operation done on 23-04-2012. As such this District Forum is not inclined to grant any relief. Therefore, this case is dismissed on contest without cost.
Supply free certified copy of judgment to the parties.
Given under the hand of the President and Members of this District Forum and seal of the Office of the District Forum on this the 5th day of August, 2017.
