FINAL ORDER/JUDGMENT
SMT. SUKLA SENGUPTA, PRESIDENT
This is an application U/s 35 of the CP Act, 2019 as amended up to date.
The fact of the case in a nutsheel is that the complainant, is a senior citizen. Her son obtained a health insurance certificate from the OP Insurance Co. which provides health insurance to public having its regional office at Unit No. 18, 4th floor, Chowrighee Road, Kolkata-700071 and also at Western Express Highway Gurgaon (East), Mumbai-40063. The one Indrajit Rana being the son of the complainant purchased the health insurance policy, vide policy No. PROHLN240010510-2020 from Manipal Cigna Health Insurance Co. Ltd. on 01.02.2020. He used to pay premium of Rs. 7,902/- only on yearly basis to the OP. At the time of purchasing health insurance policy. the son of the complainant was physically fit and no pre-existing disease was mentioned in the policy bond paper issued by the OP Insurance Co, which is annexed as annexure-A1. As per advice of the family physician, the son of the complainant was advised to admit Calcutta Medical Research Institute Kolkata on 18.09.2020 at 12.10 AM under Dr. Anirban Chatterjee, as he was suffering from symptoms of Jaundice. The prescription dated 17.11.2020 of Dr. Nirmalya Ghosh, the house physical is annexed as annexure A2.
After admission at the CMRI hospital, the son of the complainant was diagnosed to be suffering from De-compensated chronic liver disease (DCLD) with Acites .
It is further stated by the complainant that after admission at CMRI, health condition of her son was deteriorated day by and day and ultimately, he was shifted to intensive care unit on 04.12.2020 for rectal bleeding (bleeding P/R ) as per advice of treating, Dr. Anirban Chatterjee again shifted to ward on 10.12.2020 but again he was shifted to intensive care unit on 12.12.2020 due to his confuse condition. On 16.12.2020, he was shifted to HDU but again due to massive rectal bleeding, he was shifted to ICU on 20.12.2020 and ultimately, and also unfortunately, he expired on 28.12.2020 i.e. after 42 days of his admission at CMRI. The death certificate of the son of the complainant issued by CMRI is annexed as annexure-A3.
It is further stated that the final bill of the diseased was amounting to Rs. 10,92,200.00/- out of which the National Insurance Co. Ltd through TPA namely MD India Health Insurance TPA Pvt. Ltd. paid an amount of Rs. 2,58,953/- and the hospital made an discount as per agreed tariff was fixed at 7.5 % on the total bill amounting to Rs. 81,915/- . Therefore, the total amount of Rs. 3,40,868/- was settled by way of payment by National Co. Ltd. and discount made by the hospital authority . The Xerox copy of the payment sheet is annexed as annexure -A4.
The rest amount of Rs. 6,33,559/- was paid by the complainant on 31.12.2020 vide receipt no. INV-C-C-20003210 and an rest amount of Rs.1,17,773.00/- was paid by the complainant to the hospital authority out of which the hospital authority further discounted of Rs. 57,773/- and untimely, the complainant paid Rs. 60,000/- to the hospital authority (annexure-A5).
Thereafter, the complainant requested the OP insurance Co. to settle the claim through a claim form (annexure -A6). The complaint requested to OP Insurance Co. Ltd. to reimburse the claim against the amount paid by her vide letter dated 19.03.2021 and 22.04.2021 but the OP Insurance Co. rejected the claim stating that the deceased was suffering from K-C-O-hypertension since 01.03..2019 which was not disclosed at the time of purchasing the health policy vide letter dated 11.02.2022. (anneure-A8). It was stated by the attending Dr. that insured was not suffering from hypertension on 01.03.2019 when his blood pressure was 106 /74 (annexure-A8).
The complainant on several occasion through email and by post requested the OP to settle the claim and also sent letter to Senior Grievance Rederessal Officer of the OP but in vain.
Under such circumstances without having any other alternative, the complainant sent a legal notice dated 06.05.2022 to the OP insurance co. on 06.05.2022 (annexure-A14) but the OP did not give any Thereafter, the complainant is constrained to file this case against the OP Insurance Co. with a prayer to give direction to the OP to pay a sum of Rs. 6,93,559/- on account of principle claim along with interest @ 15 % p.a. till final payment till disposal of the matter to the complainant and also prayed for compensation of a sum of Rs. 2,50,000/- for harassment, mental pain and agony with litigation cost of Rs. 2,00,000/-.
The OP Manipal Sigma Co. Ltd. has contested the claim application by filing a WV denying all the material allegation leveled against it.
It is submitted by the OP that the petition of complaint is false, frivolous, and the complainant had no cause of action to file this petition of complaint.
In its WV , the OP further stated that the son of the complainant Indrajit Rana approached the OP for purchasing a health insurance policy and the complainant submitted the proposal form bearing No. PROHLN240010510 then the OP issued Pro- Health Protect Policy bearing No PORHLN240010510 for the period 01.02.2020 to 31.01.2021 subject to some specific terms and condition as stipulated the policy which governs the stand claim. The photocopy of policy certificate is annexed as annexure- 1.
The OP Insurance Co. admitted the fact that on 18.11.2020 the son of the complainant was admitted at the Calcutta Medical Research Institute as he was suffering from symptoms of jaundice. After admission in the said hospital, the insured was diagnosed with the compensated liver diagnosis with Ascites and after pro-long treatment unfortunately the insured is died in said hospital on 28.12.2022. It is also admitted that the complainant placed reimbursement claim to the OP. After receiving the claim form along with relevant documents, the OP provided the claim No. (27080081) and carefully scrutinized the available documents. then the OP rejected the claim on the ground that the insured was suffering from hypertension since 01.03.2019. So , there was suppression of pre-existing disease which stand in the way to release the claim in favour of the complainant. The copy of proposal form claim and other document is annexed as annexure 2, 3 and 4 respectively.
The OP further stated that the complainant is covered under the policy since 01.03.2020 and the insured was suffering from hyper tension since 01.03.2019. As per policy terms and conditions, non disclosure of disease in the proposal form needs to repudiate the claim U/s viii.i. Copy of policy wordings is annexed as annexure-5.
It is further stated by the OP insurance Co. in its WV that there is /was no deficiency in service on their part which is a sine qua non for the jurisdiction of consumer court. Thus, the petition of complaint is liable to be dismissed on this ground.
In view of the fact and circumstances, the points of consideration are as follows:-
- Is the case maintainable in its present form?
- has the complainant any cause of action to file the case
- Is the complainant a consumer?
- Is there any deficiency in service on the part of the OPs?
- Is the complainant entitled to get relief as prayed for?
- To what other relief or reliefs is the complainants entitled to get?
Decision with reasons
All the points of consideration are taken up together for convenience of discussion and to avoid unnecessary repetition.
On a close scrutiny of the materials, position of law as well as evidence on record, it is crystal clear that this commission has got jurisdiction in all respect to try this case.
Admittedly, the son of the complainant namely Indrajit Rana since deceased subscribed to Pro-Health Protect Mediclaim Policy from the OP Insurance Co. bearing No. PROHNN240010510 for the period on and from 01.02.2020 to 31.01.2021. It is also admitted fact that said Indrajit Rana being the son of the complainant was admitted at CMRI hospital at Kolkata on 18.11.2020 with health issue under Dr. Anirban Chatterjee with symptoms of jaundice. Subsequently, he was diagnosed to be suffering from De-compensated Chronic Liver Disease (DCLD) with Ascites but his condition was detoriated and he was shifted to Intensive Care Unit firstly, on 04.12.2020. Ultimately, on 28.12.2020 he expired at CMRI hospital. All these are evident from the annexed documents i.e. treatment sheet and discharge summary issued by CMRIC hospital and other Drs.
it is also admitted fact that thereafter, the complainant placed the claim of medical expenses diseases to the OPs Insurance Co. and that was repudiated by the OP Insurance Co. vide its letter dated 11.02.2022 (annexure-A8). Hence, this case.
From the above made discussion and from the admission of the OP Insurance Co. in its WV, evidence and written argument, it is palpably clear that the complainant being the beneficiary of the diseased Indrajit Rana is a consumer within the ambit of CP Act, 2019. It is also proved that he/she filed this case within the period of limitation and there was sufficient cause of action on her part to file this case.
Now let us see, whether there was any sort of deficiency in service on the part of the OP Insurance Co. or not as alleged by the complainant in her written complaint, evidence and argument.
On a close scrutiny of the evidence on record as adduced by the parties to this case, it is revealed that Indrajit Rana since deceased being the son of the complainant purchased the health insurance policy in question from the OP Insurance Co. on 01.02.2020 vide policy No. PROHNN240010510 and he used to pay yearly premium of Rs. 7, 902/- . It is also revealed that on the day of purchasing the policy, the insured i.e. son of the complainant was physically fit because the OP Insurance Co. used to issue the policy certificate to a person on receipt of required premium as and when the insurance company satisfied that the person is physically fit and medical certificate along with policy documents also shown in the same as got as annexure A-1. Suddenly on 17.11.2020, the insured was advised by family physician, Dr. Nirmalaya Ghosh to be get admission at CMRI hospital Kolkata. Accordingly, the insured was admitted at CMRI hospital on 18.11.2020 at about 12.10 P.M. Under one Dr. Anirban Chatterjee and prescription of Nirmalya Ghosh is annexed as annexure-2 and ultimately, the insured was diagnosed with De-compensate Chronic Liver Disease (DCLD) with Ascites and day by day his condition was deteriorated and shifted to ICU on several occasion and ultimately, after back log of 42 days he was expired at CMRI hospital on 28.12.2020. The death certificate of diseased by CMRI and death summary are annexed as annexure-A3.
The total medical expenses at CMRI hospital on and from 18.11.2020 till 28.12.2020 of the patient Indrjait Rana was amounting to Rs. 10,92,200/- out of which the National Insurance Co. Ltd through their TPA namely MD India Heath Insurance Tap Pvt. Ltd paid an amount of Rs. 2,58,953/- and the hospital made an discount amounting to Rs. 81,915/- (annexure-A4). The rest amount i.e. of Rs. 6,33,559.00/- was paid by the complainant on 31.12.2020 vide receipt No. INV-C-20003210 .
Thereafter, the amount of Rs. 1,17,773.00 was due to paid by the complainant to the hospital authority out of which the hospital authority made a discount by Rs.55,773/-. The complainant somehow managed of Rs. 60,000/- to the hospital authority along with final bill and discount letter dated 04.09.2021 by Salesh Kumar are also revealed from annexure-A5.
It is also admitted fact that the complainant placed the letter of request to the OP Insurance Co. to settle the claim of Rs. 6,93,559/- to a claim form (annexure-A6) but admittedly, the OP Insurance Co. repudiated the claim on the ground of suppression of previous disease i.e. K/C/O hypertension since 01.03.2019 and the OP Insurance Co. are alleged that the insured did not disclose at the time of purchasing the Health Insurance Policy repudiated the claim vide its letter dated 11.02.2022.
In this regard, the complainant submitted so many documents vide annexure A9, A10, A11, A12 etc but OP Insurance Co. was not convinced by such documents and arbiterally repudiated the claim .
During the course of argument Ld. advocate for the complainant has cited the case law of Hon’ble High Court Kerala in WP (C) No. 7208 to 2021 in the case of National Health Insurance Co Ltd. . Vs. Sudha Gupta in FA No. 103/2022. Wherein It has been held by the Hon’ble justice Daya Chaterjee that “even otherwise, it has been settled in a number of Judgment of various cases including Hon’ble Supreme Court and Hon’ble National Commission that Hypertension and Diabetes mellitus are not disease but common physical discourse and the same cannot be ground to deny the legitimate claiming patient/insured ”. In the instant case also the OP Insurance Co. only relied upon the discharge summary.
On the contrary, Ld. Advocate for the OP Insurance Co. argued that after getting the claim application the OP Insurance Co. scrutinized the available document and found that the insured Indrajit Rana was a known case of hypertension since 01.03.2019 and they repudiated the claim but it has already discussed above that it is also the duty of the Insurance Co. to examine the health of the insured prior to issue the policy but OP Insurance Co. issued the policy certificate to the insured then it is held by this commission that the OP Insurance Co. was satisfied with all health information of the deceased which supplied by the insured and then they issued the insurance policy but at the time of death claim, OP Insurance Co. tried to evade from their responsibility to settle the claim and took baseless plea that the insured was suffering from hypertension from 01.03.2019. In this regard, it is of view that Hon’ble Apex Court in many cases, that hypertension is a such disease which may be continue or intermittent and that by itself cannot be considered as material of disclosing in the proposal form or in the personal statement. because it is the normal wear and tear of modern day life style which is full of tension at the place of work in and out of house and are controllable on day to day basis by standard medication cannot be used as concealment of pre- existing disease for the repudiation of insurance claim.
In the instant case also the OP Insurance Co. tried to evade from his duty and responsibility to settle the claim and deliberately repudiated the claim. Being the beneficiary of the diseased, the complainant has right to get the claim in question which should be settled the favorably to the complainant by the OP Insurance Co.
In view of discussion made above, this commission is opined that there is no merit in the argument of the OP Insurance Co. and is liable to be rejected.
In view of discussion made above, the commission is of view that the complainant being the beneficiary and unfortunate, mother of the diseased placed the claim to the OP Insurance Co. and the OP Insurance Co. arbiterally and willfully repudiated the claim and harassed the complainant day by day even on received of legal notice, they did not pay any heed to the request of the complainant. Such conduct of the OP Insurance Co. is nothing but the deficiency in service on their part for which they should pay compensation to the complainant along with the claim amount.
On the basis of discussion made above, it is held by this commission that being a consumer the complainant could be able to prove her case of deficiency in service against the OP Insurance Co. beyond all reasonable doubt and is entitled to get the claim as prayed for.
All the points of consideration are considered and decided in favour of the complainant.
The case is properly stamped.
Hence,
Order
that the case be and the same is decreed on contest against the OP Manipal Sigma Health Insurance Co. Ltd. with cost of Rs. 5,000/-.
The complainant do get the decree as prayed for.
The OP Insurance Co. is directed to pay the claim amount of Rs. 6,93,559/- on account of principle claim along with interest @ 9 % pa. from the date of filing of this case till retaliation of the entire amount within 45 days from this date of order.
The OP Insurance Co. is further directed to pay a sum of Rs. 30,000/- as compensation for harassment, mental pain and agony along with litigation cost of Rs.7,000/- within 45 days from this date of order id, the complainant will be at liberty to execute the decree as per law.
Copy of the judgment be uploaded forthwith on the website of the commission for perusal
