In the Court of the
Consumer Disputes Redressal Forum, Unit -I, Kolkata,
8B, Nelie Sengupta Sarani, 4th Floor, Kolkata-700087.
CDF/Unit-I/Case No.429/2010
1) Mrs. Susan Thomas,
Flats no.3 and 4, 5th Floor, Building 24,
Brindavan Gardens, 98, Christopher Road,
P.S. Topsia, Kolkata-46. ---------- Complainant
---Versus---
1) ICICI Lombard General Insurance Co.,
ICICI Health Care, TGV Mansion, 6th Floor,
Plot no.6-2-1012, Khairtabad, Hyderabad-500004.
2) Belle Vue Clinic,
9, Loudon Street,
P.S. Shakespeare Sarani, Kolkata-17. ---------- Opposite Parties
Present : Sri Sankar Nath Das, President.
Dr. Subir Kumar Chaudhuri, Member.
Smt. Samiksha Bhattacharya, Member
Order No. 23 Dated 06-06-2013.
The case of the complainant in short is that complainant is a policy holder having policy no.4034/FFH/W-1587525/00/001 of Health Insurance Scheme of the o.p’s company. Complainant had Health Insurance Policy of o.p. company effective from 23.3.06 being policy no.4034/e-FFH/606012/00/000 wherein due to some mistake of o.p. it was not mentioned that her pre-existing illness is diabetes, though this was declared by the complainant when the policy was taken.
The above policy was renewed in the following year i.e. March, 2007 to March, 2008, the o.p. corrected their mistake and entered in the policy that her pre-existing illness is diabetes. Pre-existing illness means any condition or ailment which the insured had signs or symptoms and/or were diagnosed and/or received medical treatment within 48 months prior to the first individual health policy with the company.
The policy was renewed in the following 2 years, from March, 2008 to March,2009 and April, 2009 to April, 2010. The complainant and her husband on renewal of the policy in 2010 found to their dismay that not only the error in the policy by the other party continuous in the column of pre-existing disease but it was also mentioned as ‘none’.
On perusal of such mistakes immediately the complainant’s husband on 31.3.10 sent a letter addressed to the o.p. stating interalia that due to mistake on their part while issuing insurance policy, the column of pre-existing disease was mentioned as ‘none’. It was requested to the o.p. for making necessary corrections in the said policy since for many years, the complainant had diabetes as pre-existing illness, which also found place in her prior health insurance policy with the o.p.
Pursuant to such communication made to the o.p., the o.p. issued a modified health insurance policy effective from 7.4.10 to midnight of 6.4.11 wherein pre-existing disease was shown as diabetes. This shows that the o.p. has accepted the complainant’s claim based on o.p’s previous record.
Complainant was suffering from renal impairment due to uncontrolled diabetes, it was mandatory and compelling for her to undergo ILEAL INTEROSITON AND SLEEVE GASTRECTOMY. The said surgery was conducted by Dr. Surendra Ugale at Bellevue Clinic at Kolkata, wherein the complainant was admitted from 2.5.10 to 8.5.10 and was operated.
Complainant having claimless consecutive four years health insurance policy with the o.p. denoting her pre-existing illness as diabetes, in violation of IRDA Rules, the o.p. refused to extend cashless facility to complainant at the time of her surgery at Bellevue Clinic but requested to submit entire documents to the o.p. pursuant to which, all necessary documents including prescriptions, bills, receipts of payments made to hospital were submitted by the complainant to the o.p.
Complainant was extremely surprised to receive a letter dt.22.7.10 addressed to her husband from the o.p. company stating interalia that the complainant’s claim for reimbursement is rejected because of untrue or incorrect statement, misrepresentations, mis-description or non-disclosure at the time of policy inception.
The complainant’s husband by letter dt.5.8.10 made a representation to the o.p. seeking clarification and reasons for rejection of claim for reimbursement of the complainant. In spite of receipt of th e representation dt.5.8.10 the o.p. did not give any reply. Hence the case was filed by the complainant with the prayer contained in the petition of complaint.
O.ps. had entered their appearance in this case by filing w/v and denied all the material allegations labeled against them and prayed for dismissal of the case. Ld. lawyer of o.ps. in the course of argument submitted that the case has got no merit and the same is liable to be dismissed.
Decision with reasons:-
We have gone through the pleadings of the parties, evidence and documents in particular and we find that complainant is a policy holder having policy no.4034/FFH/W-1587525/00/001 of Health Insurance Scheme of the o.p’s company. Complainant had Health Insurance Policy of o.p. company effective from 23.3.06 being policy no.4034/e-FFH/606012/00/000 wherein due to some mistake of o.p. it was not mentioned that her pre-existing illness is diabetes, though this was declared by the complainant when the policy was taken.
We further find that the above policy was renewed in the following year i.e. March, 2007 to March, 2008, the o.p. corrected their mistake and entered in the policy that her pre-existing illness is diabetes. Pre-existing illness means any condition or ailment which the insured had signs or symptoms and/or were diagnosed and/or received medical treatment within 48 months prior to the first individual health policy with the company. And the policy was renewed in the following 2 years, from March, 2008 to March, 2009 and April, 2009 to April, 2010. The complainant and her husband on renewal of the policy in 2010 found to their dismay that not only the error in the policy by the other party continuous in the column of pre-existing disease but it was also mentioned as ‘none’.
It is seen from the record that on perusal of such mistakes immediately the complainant’s husband on 31.3.10 sent a letter addressed to the o.p. stating interalia that due to mistake on their part while issuing insurance policy, the column of pre-existing disease was mentioned as ‘none’. It was requested to the o.p. for making necessary corrections in the said policy since for many years, the complainant had diabetes as pre-existing illness, which also found place in her prior health insurance policy with the o.p. And pursuant to such communication made to the o.p., the o.p. issued a modified health insurance policy effective from 7.4.10 to midnight of 6.4.11 wherein pre-existing disease was shown as diabetes. This shows that the o.p. has accepted the complainant’s claim based on o.p’s previous record.
It is also seen that complainant having claimless consecutive four years health insurance policy with the o.p. denoting her pre-existing illness as diabetes, in violation of IRDA Rules, the o.p. refused to extend cashless facility to complainant at the time of her surgery at Bellevue Clinic but requested to submit entire documents to the o.p. pursuant to which, all necessary documents including prescriptions, bills, receipts of payments made to hospital were submitted by the complainant to the o.p.
It transpires from the record that complainant was suffering from renal impairment due to uncontrolled diabetes, it was mandatory and compelling for her to undergo ILEAL INTEROSITON AND SLEEVE GASTRECTOMY. The said surgery was conducted by Dr. Surendra Ugale at Bellevue Clinic at Kolkata, wherein the complainant was admitted from 2.5.10 to 8.5.10 and was operated.
Further we find from the record that complainant was extremely surprised to receive a letter dt.22.7.10 addressed to her husband from the oi.p. company stating interalia that the complainant’s claim for reimbursement is rejected because of untrue or incorrect statement, misrepresentations, mis-description or non-disclosure at the time of policy inception. And the complainant’s husband by letter dt.5.8.10 made a representation to the o.p. seeking clarification and reasons for rejection of claim for reimbursement of the complainant. In spite of receipt of the representation dt.5.8.10 the o.p. did not give any reply.
In view of the findings above and on perusal of the entire materials on record we find that o.p. no.1 had sufficient deficiency in service being service provider to its consumer / complainant and complainant is entitled to relief.
Hence, ordered,
That the case is allowed on contest with cost against the o.p. no.1 and without cost against o.p. no.2. O.p. no.1 is directed to pay a sum of Rs.4,02,848/- (Rupees four lakhs two thousand eight hundred forty eight) only to the complainant towards the claim of the complainant as medical expenses and is further directed to pay compensation of Rs.40,000/- (Rupees forty thousand) only for harassment and mental agony and litigation cost of Rs.10,000/- (Rupees ten thousand) only within 45 days from the date of communication of this order, i.d. an interest @ 10% p.a. shall accrue over the entire sum due to the credit of the complainant till full realization.
Supply certified copy of this order to the parties free of cost.
