BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM
CACHAR :: SILCHAR
Con. Case No. 41 of 2014
Smti. Suparna Paul
W/O- Late Jayanta Paul
C/O- Sri Shib Shankar Paul
Tarani Road, P.O- Rangirkhari, Silchar, Cachar, Assam……….. Complainant.
-V/S-
1. The Divisional Manager,
The United India Insurance Co. Ltd.
Shyamaprasad Road, P.O. & P.S- Silchar.
Dist- Cachar (Assam) ……………………..……………… O.P.No.1.
2. Medi Assist India TPA Pvt. Ltd.
53, A-Rafi Ahmed Kidwai Road,
1st Road (Bata More)
Kolkata-700016 ……………………..………………. O.P.No.2.
Present: - Sri Bishnu Debnath, President,
District Consumer Forum,
Cachar, Silchar.
Sri Kamal Kumar Sarda, Member,
District Consumer Forum,
Cachar, Silchar.
Appeared: - Mr. Pulak Bhattacharjee Advocate for the complainant.
Mr. Dipak Kumar Deb Advocate for the O.P.No.1.
None for O.P.No.2
Date of Evidence 18-08-2017
Date of written argument 20-06-2018
Date of oral argument 13-09-2018, 02-11-2018
Date of judgment 16-11-2018
JUDGMENT AND ORDER
Sri Bishnu Debnath
- This Complaint under the provision of the Consumer Protection Act. 1986 has been brought against the Divisional Manager, the United India Insurance Co. Ltd. Silchar and against Medi Assist India TPA Pvt. Ltd. Kolkata for award of sum insured in connection with Insurance Policy No. 130500148/11/06/00000550 and other compensation for disservice etc.
- The brief fact:-
Jayanta Paul purchased Medi-Care Policy for his wife, two daughters and for himself on 13/10/2009 vide policy No. 130500/48/09/06/00000720 for the period from 13/10/2009 to 12/10/2010. Sum Insured was Rs. 1,00,000/-. Subsequently the policy renewed for the period from 13/10/2010 to 12/10/2011 and from 13/10/2011 to 12/10/2012. Each time the United India Insurance Co. issue fresh renewed policy with new policy number. Anyhow, due to some abnormalities in his body the Jayanta Paul was admitted to hospital on 23/03/2012 and during the course of treatment shifted to GNRC, Guwahati and then to other private hospital and subsequently took his last breath at Silchar Medical College & Hospital on 10/05/2012. The cause of death as per doctor’s opinion is Metabolic Encephalopathy. He is referred in this Judgment as deceased.
- However, the wife of the deceased Jayanta Paul being the Complainant of this case submitted Medi-Claim to the Divisional Manager, the United India Insurance Co. Ltd. but the said O.Ps repudiated the claim vide letter dated 20/12/2013. Hence, this case for award of sum insured of Rs.1,00,000/- and other compensation as per law & equity.
- The O.P. No. 1 i.e the Divisional Manager, United India Insurance Co. Ltd submitted W/S. In the W/S stated inter alia that the claim has been repudiated because as per discharge summary of the deceased Jayanta Paul, he had history of Hypertension & Diabetes Mellitus for 3-4 years and on regular medication. Which means he suppressed his disease at the time of purchasing the insurance policy. As such claim is not entertained as per terms and condition of policy claim No.4.1. The O.P.No. 2 did not contest the case.
- During hearing the Complainant submitted deposition and exhibited relevant Medical papers including Hospital Discharge certificate. The O.P.No.1 also submitted deposition of Burhan Uddin Hazari and exhibited Insurance Policy, repudiation letter, case summary & discharge record of deceased Jayanta Paul vide Ext.A, Ext.B & Ext.C respectively. After closing evidence the Ld. Advocate of the Complainant submitted written argument but the O.P. side did not take the scope to submit written argument.
- In this case on perusal of W/S, evidence and argument it is concluded that the claim has been repudiated because the deceased of Jayanta Paul suppressed his pre-existed disease of Hypertension and Diabetes in the Policy documents. The Complainant did not agree with the plea of the O.P. Thus, it is the onus of the O.P. to establish the fact that prior to the date of purchasing the Medi-Care Policy on 13/10/2009 the deceased Jayanta Paul was suffering from Hypertension & Diabetes. Accordingly, the O.P.No. 1 exhibited case summary & discharge record issued by GNRC Guwahati vide Ext.C. As per that documents past history is recorded as “H/O hyper tension for 3-4 years on regular medication. H/O Diabetes mellitus for 3-4 years on irregular medication”.
- But on careful perusal of evidence on record I do not find the exact date of detection of Hypertension & Diabetes. Moreover, no documentary proof is found in the discharge summary to support the above opinion. That is why, from available material on record it is not possible to determine conclusively that deceased was suffering from Hypertension & Diabetes prior to the date of purchasing the Medi-Care Insurance Policy. As such in my considered view the O.P. has not been able to establish the defense plea as above beyond doubt. So, the Complainant is entitled to get sum insured of Rs.1,00,000/-(Rupees One Lakh) only as per the policy terms & condition and also entitled to get compensation for mental agony of Rs.25,000/- (Rupees Twenty Five Thousand) only and cost of proceeding of Rs.5,000/- (Rupees Five Thousand) only.
- Therefore, the O.P. No.1 is asked to make payment of above awarded amount of Rs.1,30,000/- (Rupees One Lakh Thirty Thousand) only within 45 days from today. In default interest at the rate of 10% per annum to be added till realization of the full.
- With the above the case is disposed of on contest. Supply free certified copy of Judgment to the parties. Given under my hand and seal of this District Forum on this the 16th day of November, 2018.
