IN THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, MURSHIDABAD AT BERHAMPORE.
CASE No. CC/160/2017
Date of Filing: Date of Admission: Date of Disposal:
18.09.2017 22.09.2017 11.04.2023
Complainant: Mahabrata Mondal,
S/o – Madan Mohan Mondal,
149/5, Pilkhana Road (Ranibagan)
P.O. & P.S.-Berhampore,
Dist- Murshidabad, W.B. Pin-742101
-Vs-
Opposite Party: 1. The Divisional Manager,
Berhampore Division,
New India Assurance Co.ltd.
37A, R.N. Tagore Road (Laldighi)
P.O. & P.S.-Berhampore, Murshidabad,
Pin-742101
2. The Administrator,
Heritage health Insurance TPA Pvt. Ltd.,
NICCO House (5th Floor) 2, Hare Street,
Kolkata-700001.
Agent/Advocate for the Complainant : Sadhan Kumar Saha
Agent/Advocate for the Opposite Parties : J Bhattacharjee
.
Present: Sri Ajay Kumar Das…………………………..........President.
Sri. Nityananda Roy…………………………………….Member.
FINAL ORDER
Sri. Ajay Kumar Das, Presiding Member.
This is a complaint under section 12 of the CP Act, 1986.
One Mahabrata Mondal (here in after referred to as the Complainant) filed the case against the Divisional Manager, Berhampore Division, New India Assurance Co. Ltd. and Anr. (here in after referred to as the O.P.s ) praying for compensation alleging deficiency in service.
The sum and substance of the complaint case is as follows:-
The Complainant had taken an individual Health Insurance Policy being no. 51290034142800000243 for the period from 22.12.14 to 21.12.15 and on the next year he took Health Insurance Policy being no. 5129003415200000367 for the period from 22.12.15 to 21.12.16 and then for the period from 22.12.16 to 21.12.17 he took Health Policy being no. `51290034162800000436 and according to terms and conditions of the said policy the Complainant’s wife and daughter have been included in the said policy and the said policy was amounting to Rs. 2,00,000/-. During that period he was suffering from Floaters deceased Reoccassional flashes, and shades in the right eye and he was treated by Disha Eye Hospital Pvt. Ltd.88 (63AO, Ghospara road, Barrackpore, Kolkata-700120 and admitted on 26.12.14 and discharged on 26.12.14 on such date he was treated by Micro Coaxial Phaco with aleon at Disha Eye Hospital Pvt. Ltd. After the said treatment the Complainant felt uneasy in his right eye due to “pseudophakic S/P laser Barrage Rhegmatogenous sub-total Ratinal detachment” and the Complainant was under gone surgical operation on his right eye at Sankar Netralaya an unit of Medical Research Foundation-JKCN at 21, Pycoofts Garden Road Nungambahkam Chennai-600006, Tamil Nadu, India and the Complainant has borne much expenses in this regard he submitted Mediclaim form with requisite documents and bills in the office of the O.P. No. 1 who took efforts to enquire the matter by O.P. No. 2. Subsequently the O.P. No.1 issued a letter to the Complainant that the bill under the claim form as submitted, was not admissible under the clause of the NIA terms and conditions. This observation is vague and baseless as the Complainant has under gone all sorts of treatment in his right eye which was covered under the above Health Insurance policies. The Complainant has informed about the surgical treatment on his right eye, to the OP No 1 on 24.11.16 and on 07.12.16 the Complainant submitted claim form on 07.12.16. The O.P. No. 1 avoided paying the claimed amount by their letter no. 51290034/SKD/2017 dated 6-6-17 as a regular practice and which is unreasonable and unjustified. So, Complainant suffered much mental agony and the monetary loss involved in the said treatment.
Finding no other alternative the complainant filed the instant case before this District Commission praying for an order directing the O.P.s .to pay Rs. 36000/- which has been spent by the Complainant and also pass an award for Rs. 10,000/- towards harassment along with interest @ 12% p.a. as well as mental agony of the Complainant.
Defence Case
The O.P. Nos. 1 & 2 are contesting the case by filing W/V contending inter alia that the case is not maintainable. The specific case of the O.P.s is that the claiming form submitted by the Complainant is vague, malafide, excessive, baseless and imaginary and the O.P.s are not liable to pay the claim and any portion of it as it was not admissible under the terms and conditions of the policy. According to Clause 2.15, 4.1, 4.2 and the 4.3.1 of the terms set out in this policy the Complainant is not entitled to get any award from the O.P.s.
They have further stated that as far as clause 4.1 of the terms set out in that policy no claim is payable under the policy in case of treatment of any pre-existing condition/decease, until 48 months of continuous of coverage of such insured person have elapsed from the date of inception of his/her first policy as mentioned in the schedule.” It is the case of the claimant that he has taken the policy on 22.12.14 and as he was suffering from eye decease he was admitted to Disha Eye Hospital on 26.12.2014 i.e., he was treated after 4 days of the commencement date of this policy and as such he is not entitled to get any award from this policy.
What are excluded under this policy “ it has clearly mentioned in Clause 4 of the terms set out in the policy. It is also clear from the terms set out in clause 4.2 of the policy that no claim is payable for “any illness contracted by insured person during the first 30 days commencement date of the policy.”
Admittedly, the claimant was admitted for his treatment on 26.12.2014 in Disha Eye Hospital Pvt. Ltd. at Barrackpore and the commencement date of this policy is on 22.14.2014 i.e., he was treated after 4 days of commencement date of this policy. As per clause 4.2 of the terms set out in this health insurance policy he is not entitled to get any benefit from this health insurance policy. Moreover, clause 4.3.1 is clear bar to get any benefit in this regard. Suppressing his preexisting decease the claimant has taken this health insurance policy and as such he is not entitled to get any relief.
On the basis of the complaint and written version the following points are framed for proper adjudication of the case:
Points for decision
1. Is the Complainant a consumer under the provision of the CP Act, 1986?
2. Have the OPs any deficiency in service, as alleged?
3. Is the Complainant entitled to get any relief, as prayed for?
Decision with Reasons:
Point no.1
Ld. Advocate for the Complainant submits that he is a consumer to the O.P.s. This fact is not challenged by the O.P.s. Keeping in mind the submission of the both sides and considering the materials on record we are of the view that the Complainant is a consumer to the O.P.s.
Point no.2 & 3
Both the points are taken up together for the sake of convenience and brevity of discussion. Ld. Advocate for the Complainant submits that he had taken health insurance policy for the period from 22.12.2014 to 21.12.2015, 22.12.2015 to 21.12.2016 and for the period from the 22.12.2016 to 21.12.2017. The Complainant was treated by Disha Eye Hospital Pvt. Ltd and was admitted on 26.12.2014. Though he was admitted after 4 days from the date of inception of the policy but he did not claim any amount for the said treatment. Ld. Advocate for the Complainant further submits that he was admitted to Medical Research Foundation, Chennai, Tamil Nadu on 24.11.2016 and thereafter the Complainant was discharged on 26.11.2016 and the amount to medical expenses was Rs. 36,807/-. He prays for compensation of that amount and for Rs. 10,000/- as mental pain and agony. He submits that in support of his contention he has submitted the relevant documents (photocopies).
Ld. Advocate for the O.P.s submits that the Complainant has suppressed the treatment of preexisting condition/deceased as it is evident from the complaint that the Complainant was admitted on 26.12.2014 which was just after 4 days for the commencement date of the policy.
On this point Ld. Advocate for the Complainant cited a judgment reported in National Insurance Co.Ltd. Vs. Raj Narain 2008 NCJ 559 (NC) wherein the Commission had, inter alia, observed as follows:
“Most of the people are totally unaware of the symptoms of the disease that they suffer and hence they cannot be made liable to suffer because the Insurance Company relies on their Clause 4.1 of the policy in a mala fide manner to repudiate all the claims. No claim is payable under the medi-claim policy as every human being is born to die and diseases are perhaps pre-existing in the system totally unknown to him which he is genuinely unaware of them. Hindsight everyone relies much later that he should have known from some symptom. If this is so every person should do medical studies and further not take any insurance policy.”
In view of the above legal position we are of the view that the question of pre-existing decease raised by the Ld. Advocate for the O.P.s is not tenable.
Ld. Advocate for the O.P.s submit before this District Commission that the Complainant was admitted to Medical Research Foundation, Chennai, Tamil Nadu on 24.11.2016 and was discharged on 26.11.2016 which is within 24 months from the date of commencement of the first health insurance and as such the Complainant is not entitled to get any claim as per the Clause 4.3.1 of the terms set out in the policy. We perused the terms and conditions of the policy and we found that the Complainant underwent right eye operation within 24 months from the date of commencement of the first health insurance policy and as such the claimant is not entitled to get any benefit as prayed for.
Reasons for delay
The Case was filed on 18.09.2017 and admitted on 22.09.2017. This Commission tried its level best to dispose of the case as expeditiously as possible in terms of the provision under section 13(3A) of the CP Act, 1986. Delay in disposal of the case has also been explained in the day to day orders.
In the result, the Consumer case fails.
Fees paid are correct. Hence, it is
Ordered
that the complaint Case No. CC/160/2017 be and the same is dismissed against O.P.s on contest but under the circumstances without any order as to costs.
Let plain copy of this order be supplied free of cost, to each of the parties / Ld. Advocate/Agent on record, by hand /by post under proper acknowledgment as per rules, for information and necessary action.
The Final Order will also be available in the following Website:
confonet.nic.in
Dictated & corrected by me.
President
Member President.
