West Bengal

Paschim Midnapore

CC/78/2014

Sri Dipankar Neogi. - Complainant(s)

Versus

Managing Director, Bajaj Allianz General Insurance Co. Ltd. - Opp.Party(s)

04 Feb 2016

ORDER

                                                           DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

PASCHIM MEDINIPUR.

                             

Bibekananda Pramanik, President

and

Kapot Chattopadhyay, Member.

   

Complaint Case No.78/2014

                                                       

                                        Sri Dipankar Neogi…………………………….….……Complainant.

Versus

 

1)Managing Director, Bajaj Allianz General Insurance Company Ltd.,

2)Branch Manager, M/s Bajaj Allianz General Insurance Company Ltd.

                                                   …………………...........Opp. Parties.

 

              For the Complainant: Mr.  Pradip Kumar Neogi, Advocate.

              For the O.P.               : Mr. Pinaki Sengupta, Advocate.

 

Decided on: - 04/02/2016

                                                 

ORDER

                          Bibekananda Pramanik, President – Facts of the case, in brief, is that on 01/03/2013, the complainant took a Mediclaim Policy in his name as insured from the opposite party no.1 and the beneficiary of the said policy was his minor son Subhrajyoti Neogi. Said policy was valid from 01/03/2013 to 28/02/2014 under the policy name “Star Package” being Medical Insurance policy no.OG-13-2410-6009-00000013.  At the time of taking the said policy, the opposite party no.1 did not disclose the exclusion clauses and other terms and conditions of the policy to the complainant.  In the body of the premium receipt/policy, it is mentioned that the Mediclaim Insurance Policy is a “Star Package” policy but the premium receipt did not disclose what it actually meant for “Star Package”.  It is also not mentioned how the policy holder will be accommodated in case of critical illness and what are the criteria for getting insurance coverage.  The beneficiary of the said

Contd……………..P/2

 

 

 

( 2 )

Mediclaim Insurance policy Subhrajyoti Neogi became seriously ill on 31/05/2013 and he was treated by Dr. Samir Kumar Roy as well as Dr. A.K. Hazra, who advised the complainant to admit Subhrajyoti Neogi in the hospital for better treatment.  As per instruction of Dr. A.K. Hazra,  the complainant got his son Subhrajyoti Neogi admitted in  Midnapore Medical Collage and Hospital on 31/05/2013 and after thorough examination and clinical test, he was referred to Nilratan Sarkar Medical Collage & Hospital.  On 31/05/2013, Subhrajyoti Neogi was admitted at Apollo Gleneagles Hospital, 58 Canal Circular Road, Kolkata and he was treated  by Dr. P.S. Bhattacharya and after medical examination, it was detected that Subhrajyoti Neogi was facing “left posterior communicating artery (P com) is prominent focal 2.4 x 2.3 m.m vascular prominent focus noted in relation to left posterior inferior cerebeller artery (PLCA) may represent vascular loop/aneurysm and the above noted observation has been confirmed by Dr. Somnath Chhatterjee, MD (PGI, Chandigarh) DM (SCTIMST) FRCP (UK), Dr Usha Goenka, MD, Head Department of IMAGING.  Finally Subhrajyoti died on 05/06/2013 at 2.45 p.m.  Thereafter the complainant submitted claim form before the opposite parties but the complainant’s genuine claim of Rs.1,75,000/- has been turned down by the opposite parties on 24/09/2013 by a letter of repudiation.  On 22/11/2013 and 28/02/2014, the complainant gave another representations to the opposite party-Insurance Company requesting them to consider the death claim due to untimely death of Subhrajyoti Neogi,  but of no good.  It is stated that the claim of the complainant is very much genuine and he is entitled to get Rs.1,18,775 + Rs.56,225/- for treatment, medicine and ambulance fees etc.  Hence the complaint praying for an award of Rs.1,18,775 + Rs.56,225/- for initial treatment, medicine and ambulance fees towards mediclaim, Rs.50,000/- for mental agony, Rs.50,000/- for harassment cost and Rs.25,000/- towards litigation cost, total amounting to  Rs.3,00,000/- only against the opposite parties.

                  The opposite parties have contested this case by filling a written statement. Denying and disputing the case of the complainant, it is the specific case of the opposite parties that Subhrajyoti Neogi was covered under “Star Package” being Mediclaim Insurance policy no.OG-13-2410-6009-00000013 for the period of one year i.e. from 10/05/2013 to 09/05/2014 and from the said policy it will appear that there are some exclusion clauses and according to the terms of the policy it will be found that “Convalescence, general disability, rest cure, congenital external diseases or defects or anomalies, genetic disorders, stem cell implantation or surgery or growth hormonetherapy.”  From the documents i.e. medical report of deceased insured Subhrajyoti Neogi, it is found that the aforesaid insured died due to INTRACEREBRAL HAENORRHAGE AND INRABENTRICULAR HEMORRHAGE. The deceased was

Contd……………..P/3

 

 

 

( 3 )

only 7 years old and he died due to “Intractable Intracranial hypertension + Brain Herniation”.  From the medical certificate, it will be found that there were no visible and external injuries to have sustained by the deceased. Further according to the opposite party, the brain Herniation is a nature of genetic disease which is not covered under the “Star Package” policy and therefore the opposite party- Insurance Company rightly repudiated the claim.  It is further stated that the exclusion clauses were within the knowledge of the insured and after knowing the terms and conditions of the policy, the insured entered into the contract of insurance policy.   The opposite party, therefore, claimed dismissal of the complaint with cost.  

Point for decision

                    

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

                   

Decision with reasons

 In this case, neither the complainant nor the opposite party adduced any sort of evidence, either oral or documentary.  However, they have relied upon some documents,  so filed by them in this case.

 From the respective pleadings of the parties, it appears that admittedly the complainant had a Mediclaim policy in his name as insured and the beneficiary of the policy was his minor son Subhrajyoti Neogi  and the name of the said policy was  “Star Package” which was valid from 01/03/2013 to 28/02/2014.  It is not denied and disputed that the beneficiary of the said Mediclaim policy Subhrajyoti Neogi was admitted at first in Medinipur Medical Collage & Hospital on 31/05/2013 and thereafter he was referred to NRS Medical Collage & Hospital as he was suffering from cerebral vascular and on the same day he was admitted in Apollo Gleneagles Hospital, Kolkata and received treatment under Dr. P.S. Bhattacharya and he died in the said hospital on 05/06/2013 at 2.45 p.m.  It is also not denied and disputed that after the death of Subhrajyoti Neogi, the complainant being the father of the deceased and insured of the policy, submitted claim form for Mediclaim benefit and the opposite parties vide their letter dated 24/09/2013 repudiated the claim of the complainant on the ground that the deceased died due to genetic disorder which does not extend coverage of any expenses incurred for the treatment related to genetic disorder.  From the petition of complaint, we find that the complainant has pleaded that at the time of entering into the said agreement of mediclaim policy, he was in dark about such exclusion clauses and the opposite parties also did not disclose the complainant regarding such

Contd……………..P/4

 

 

 

( 4 )

exclusion clauses.  Further according to the complainant, the death certificate of Subhrajyoti Neogi would show that the cause of death of Subhrajyoti Neogi was “Intractable Intracranial Hypertension + Brain Herniation”.  As against this, it is the case of the opposite parties that from the documents i.e. medical report of deceased/insured Subhrajyoti Neogi it is found that the aforesaid insured died due to INTRACTABLE INTRACARNIAL HYPERTENSION + BRAIN HERNIATION which was caused from INTRACEREBRAL HAEMORRHAGE AND INTRAVENTRICULAR HAEMORRHAGE.  It is contended by the Op. that brain hemiation is a nature of genetic disease and such genetic disease is within the exclusion clauses of the policy and the policy does not extend coverage for any expenditure incurred on the treatment related to genetic disorder.  Opposite party adduced no evidence to show that such terms and conditions of the policy including the exclusion clauses of the policy were disclosed and explained to the complainant at the time of agreement of the mediclaim policy.  From the said medical policy, we find that nowhere in that policy it has been mentioned that the terms and conditions of policy were communicated to the insured. Since it is not proved that the terms and conditions of the policy including exclusion clauses were disclosed to the complainant, so the opposite parties cannot claim the benefit of the said exclusion clauses.  Regarding the cause of death of the deceased, we find from the death certificate that the immediate cause of death of Subhrajyoti Neogi was Intractable Intracranial Hypertension + Brain Herniation.  The opposite party adduced no evidence to show and to prove that the said cause of death was due to genetic disorder  and  that the said disease  was pre-existing on the date of commencement of the policy.  Even if the deceased was suffering from any such disease which admittedly do not occur over night, it is both possible or plausible that the insured was unaware of it since this can be silent disease and it is the settled law that a person suffering from such disease may not even be aware until the condition aggravates and overt symptoms appear.  In this case, the opposite party has adduced no evidence that the complainant was aware of or had taken treatment for such deceased prior to entering into such agreement of mediclaim policy.  Keeping in view of these facts, we are of the opinion that the opposite party was not justified in repudiating the claim of the mediclaim policy on the ground of alleged exclusion clauses of genetic disorder.  The petition of complaint is therefore deserves to be allowed.  We find from the prayer of the complainant as well as from the medical papers, submitted by the complainant, that for such treatment of the deceased, the complainant had incurred medical expenses of Rs.1,78,775/- in Apollo Gleneagles Hospital.  Prior to that, as we find from the documents filed by the complainant,  the deceased was treated by doctors and in hospital.  Complainant has prayed an award of Rs.56,225/- for initial treatment of his son Subhrajyoti Neogi apart

Contd……………..P/5

 

 

 

 

( 5 )

from his claim of Rs.1,18,775/- total Rs.1,75,000/-.  The complainant is entitled to get the said amount of Rs.1,75,000/- under the said mediclaim policy of “Star Package”.  Apart from that, the complainant is entitled to an award of Rs.25,000/- towards harassment, mental agony and litigation cost.                   

 

                                                    Hence, it is,

                                                     Ordered,

                                                          that the complaint case no.78/2014  is allowed on contest. The opposite party is directed to pay Rs.1,75,000/- to the complainant towards mediclaim under “Star Package” policy and   Rs.25,000/- towards harassment, mental agony and litigation cost within a month from this date of order.

                 Dictated & Corrected by me

             

                           President                                    Member                                  President

                                                                                                                          District Forum

                                                                                                                      Paschim Medinipur