West Bengal

Paschim Midnapore

CC/98/2016

Mr. Pritikana Nayak - Complainant(s)

Versus

Manager, National Insurance Co. Ltd. - Opp.Party(s)

27 Apr 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

PASCHIM MEDINIPUR.

                             

Bibekananda Pramanik, President,

and

 Sagarika Sarkar, Member.

   

Complaint Case No.98/2016

 

             Ms. Pritikana Nayak of Sukanta Pally,  Malancha Road, P.O. Nimpura, Police Station,

             Kharagpur Town, Dist. Paschim Medinipur, PIN-721304.………..……Complainant.

                                                                              Vs.

             Branch In-Charge/Manager, National Insurance Company Limited, Kharagpur Branch,

             Kusum Building, 1^st floor, O.T. Road, INDA, Kharagpur, PIN-721305....….Opp. Party.

                                                    

              For the Complainant: Mr.  Amiya Kumar Sahu, Advocate.

              For the O.P.               : Mr. Anath Bandhu Ghosh, Advocate.

 

Decided on: -27/04/2017

                               

ORDER

                          Bibekananda Pramanik, President – This is a case u/s 12 of the C.P. Act,  filed by Smt. Pritikana Nayak against National Insurance Co. Ltd.

                          Facts of the case, in brief, are that the complainant purchased a mediclaim policy being policy no.153802/48/14/8500001109 in the name of her father Panchanan Nayak, since deceased, from the O.P.- Insurance Company and the said policy covered the period from 18/02/2015 to 17/02/2016.  The premium under critical illness have been paid for Rs.2,288/- with a condition of additional payment upto Rs.2,00,000/- in case of critical illness under Varistha Mediclaim.  Father of the complainant thereafter was attacked with a stroke on 22/04/2015 and the complainant admitted her father in the nursing home of their house physician.  Thereafter the complainant transferred her father for better treatment to Institute of Neurosciences Centre, Kolkata on 23/04/2015 and there the

Contd……………..P/2

 

 

( 2 )

condition of her father became deteriorated further with multi failure problem. The said Institute of Neurosciences Centre is a single phase super speciality hospital and they were facing  lot of problem to treat such a patient and they advised the complainant to shift her father to any other hospital having  multi speciality function with neuroscience facility and then the complainant contacted Peerless Hospital and got her father  admitted in Peerless Hospital for better treatment. After few days, her father died on 09/05/2015.  The complainant thereafter lodged a claim for payment of the mediclaim policy under Varistha Mediclaim before the O.P.-Insurance Policy but the O.P.-Insurance Company rejected the claim by their letter dated 07/08/2015 on the ground that the “Stroke” does not cover under critical illness.  It is stated by the complainant that she submitted all documents in support of her claim thereby satisfying the condition of critical illness but the respondent again sent a letter to the complainant that the claim cannot be admitted as per provision of 11.2 of section II of the literature of the said policy.  It is further submitted that neither such condition  was explained  at the time of obtaining the policy  nor the existence of such provision was known to the respondent authority.  It is stated that with a fraudulent intention, the O.P.-Insurance company repudiated the claim in question thereby causing mental agony and financial loss to the complainant and her family.  Hence the complaint, praying for directing the O.P. to pay Rs.2,00,000/- and  additional expenses of Rs.80,000/- towards Varistha Mediclaim insurance policy.

                  The opposite party-Insurance Company has contested this case by filling a written objection.

                  Denying and disputing the case of the complainant, it is the specific case of the opposite party-Insurance Company that third party administrator  checked up the medical documents and terms and condition of the policy and on such process it was disclosed that the complainant is not entitled to get benefit of the aforesaid mediclaim policy as the said illness of the complainant’s father was first diagnosed on or after 23/04/2015 as per clinical summary of  Institute of  Neurosciences, Kolkata and the patient expired on 09/05/2015 as per final bill of National Neuroscience Center, Kolkata.  Hence the survival period clause of the Varistha Mediclaim policy is applicable in this case because the patient expired before completing 30 days after the diagnosis of the said specified illness and the said information was communicated by the O.P.-Insurance Policy to the complainant by their letter dated 20/05/2016.  It is also stated by the O.P.-Insurance Company that the complainant’s claim does not fall under critical illness section of the Varistha Mediclaim policy and so the said claim is not payable under this policy.

Contd……………..P/3

 

 

( 3 )

 Regarding non-explanation of the terms and condition of the policy, it is stated by the O.P.-Insurance Company that the said allegation is false and frivolous as because the complainant’s father was well aware about the said terms and conditions of the policy.  It is also stated by the O.P.-Insurance Company that as per terms and conditions of the policy, the claim was not maintainable and as such there is no deficiency in service on the part of the O.P.   O.P. therefore claims dismissal of the petition of complaint with cost.

                     To prove her case, the complainant has examined herself as PW-1 by tendering a written examination-in-chief and during her evidence, four documents were marked as exhibit 1 to 4 respectively.  On the other hand, O.P.-Insurance Company adduced no evidence although they were given opportunity to adduce evidence.  Of course, the O.P.-Insurance Company has relied upon some documents, so filed by them.

 

                                                                 Points for decision

1)Is the case maintainable in it’s present form and prayer?

2)Is there any deficiency in service on the part of the opposite party?

3)Is the complainant entitled to get the reliefs, as sought for?    

                   

Decision with reasons

    For the sake of convenience and brevity, all the above points are taken up together for consideration.

   It is not denied and disputed that Panchanan Nayak, since deceased, the father of the complainant obtained a mediclaim policy no.153802/48/14/8500001109 covering the period from 18/02/2015 to 17/02/2016 from the O.P.  It is also not denied and disputed that the said Panchanan Nayak, since deceased, the father of the complainant, was admitted in Institute of Neurosciences Centre, Kolkata on 23/04/2015 after being attacked in a stroke and thereafter he was referred to Peerless Hospital for better treatment where he succumbed to death on 09/05/2015.  It is also admitted by the parties that after the death of Panchanan Nayak, the present complainant being  one of the daughters of the deceased policy holder, submitted a claim of insurance before the O.P.-Insurance Company and the O.P.-Insurance Company repudiated the said claim of Varistha Mediclaim vide their letter dated 20/05/2016 on the ground that the patient was first diagnosised on 23/04/2015 and he expired on 09/05/2015.  Survival period clause of Varistha Mediclaim policy is applicable in this case because the patient expired before completing 30 days after the diagnosis of the said specified illness.  According to the complainant, as stated in his petition of complaint that

Contd……………..P/4

 

 

( 4 )

such condition was not explained at the time of selling the policy nor the existence of such provision was known to the complainant.  It appears from the cross-examination of PW-1, Pritikana Nayak, the complainant that her father was a railway employee and he was an educated person.  Since the deceased-insured was admittedly an educated person and an employee of Indian Railway, so it should be presumed that after knowing all the terms and conditions of the policy, he obtained such policy from the O.P.-Insurance Company and as such it cannot be said that such terms and conditions were not known to the insured at the time of obtaining the policy.  It appears from a document filed by the O.P. on the date of hearing of argument that in column 3.5 of Varistha Mediclaim policy it has been mentioned under heading “Survival Period” in clause 3.5 that the insured need to survive for 30 days after the diagnosis of the critical illness in order to make a claim.  We have already stated that admittedly the deceased insured was attacked with such critical illness and was admitted in Institute of Neurosciences Centre, Kolkata on 23/04/2015 and he thereafter died on 09/05/2015 in Peerless Hospital.  It thus appears that the deceased insured did not survive for 30 days after his diagnosis of critical illness on 23/04/2015.  Therefore  in view of clause 3.5 regarding survival period of Varistha Mediclaim policy, the O.P.-Insurance Company rightly repudiated the claim of Insurance of Varistha Mediclaim and therefore it cannot be held that the O.P.-Insurance Company had any deficiency in service in repudiating the claim of insurance. 

       All the points are accordingly disposed of. 

       In the result, the complainant case fails.               

                                      Hence, it is,

                                       Ordered,

                                       that the complaint case no.98/2016  is hereby dismissed on contest but in the circumstances without cost.

                               Let plain copy of this order be given to the parties free of cost.

                 Dictated & corrected by me

                    Sd/-B. Pramanik.                  Sd/- Sagarika Sarkar                   Sd/-B. Pramanik.

                            President                                 Member                                    President 

                                                                                                                         District Forum

                                                                                                                     Paschim Medinipur