DEBASIS BHATTACHARYA:- PRESIDING MEMBER

 The instant case filed under section 12 of the Consumer Protection Act 1986 arises out of the grievances of the complainant in the matter of repudiation of a claim against a medical Insurance policy under the title ‘National Mediclaim’ of National Insurance Company Ltd. (hereinafter referred to as OP 1) held by him during the material period.

The brief facts of the case is that a policy under the name ‘National Mediclaim’ was incepted in favour of the complainant, his wife and his son by the OP 1 in the year 2014 which reportedly covered the risk of the health of the complainant and initially was valid for the period 12.10.14 to 13.10.15. Subsequently the same was renewed and the extended validity period was 14.10.15 to 13.10.16. Sum insured individually for the Complainant himself was 1,75,000/-

The complainant claims to have paid all the due premiums in regular manner.

However during the continuance of the policy, the complainant fell indisposed, detected “Double Vessel Coronary artery disease’ and had to take admission in a hospital and incur expenses to the tune of Rs.1,91,680/- towards medical expenses.

On being discharged, the complainant lodged the necessary claim for reimbursement of the treatment expenses before the Opposite Parties on 06.06.2016.

However on being asked by the OP 2 i.e the third part agency, the Complainant submitted supporting medical documents related to his treatment on 04.08.16.

Thereafter, the Complainant waited for a substantial period and eventually getting no response from the other end, sent a legal notice on 03.03.17. However the same also yielded no result.

Thus cause of action arose on 03.03.17 when the legal notice was dispatched.

Considering the same as deficiency in service, willful negligence and unlawful activities causing mental agony, anxiety, harassment and financial loss, the complainant filed the complaint petition seeking direction upon the opposite party 1 to pay a sum of Rs.1,91,680/- towards treatment expenses along with interest @18% p.a. with effect from 06.06.16, Rs.2,00,000/- as compensation for mental pain, agony and harassment and to pay Rs.10,000/- towards cost of litigation.

The complainant along with his petition has submitted copies of the relevant documents related to the policy and the corresponding claim viz. policy schedule, claim form, comprehensive medical documents, in-patient medical record, case history form, discharge summary, medical bills, query of third party agency i.e. OP 2 and the legal notice sent to the opposite parties.

Evidence on affidavit filed by the complainant is almost a replica of the complainant petition.

The opposite party 1 contested the case by filing elaborate rebuttals in their written version (which on request is treated as evidence on affidavit), denying therein most of the allegations leveled against them.

On examination of the extant records it transpires that the OP 2 never appeared before this forum and thus the case naturally ran ex parte against them.

    In view of the above discussion and on examination of available records, it transpires that the complainant is a consumer as far as the provisions laid down under Section 2(1)(d) of the Consumer Protection Act 1986 are concerned.

One of the opposite parties, at the time of institution of the complaint had a branch office within the district of Hooghly. The claim preferred by the complainant does not exceed the limit of Rs.20,00,000/- Thus this Commission has territorial as well as pecuniary jurisdiction to proceed in the instant case.

Materials on records are perused.

It will be worth mentioning that the Complainant has not mentioned in his petition in categorical terms whether his claim was repudiated by the OP Insurance Company. He initiated the Complaint petition simply because of non-receipt of any response from the OP Insurance Company’s end so far his claim was concerned.

But the OP Insurance Company in their representations clearly admits in clause 11 of the written version that the claim was repudiated by them.

Now in the written version which is treated also as evidence on affidavit, the OP Insurance Company while rebutting to the charges framed by the Complainant, applies some routine adjectives like “not maintainable’, ‘bad by the principles of estoppels, waiver and acquiescence’ etc. However no specific reason is assigned for using these terms. The OP 1 even goes to the extent of claiming that statements made in para-8 of the complaint petition is false, incorrect and  concocted and there was no cause of action for filing this case.

However, OP 1 admits the inception of the policy, renewal of the policy, admission of the Complainant in hospital with ‘Double Vessel Coronary Artery Disease’.

On scrutiny of the medical documents submitted by the Complainant, OP 1 discovered from the past medical history incorporated in the discharge summary that the complainant’s mother was ‘Hypertensive’. The desperate search for a reason to repudiate the claim thus was successful and the OP jumped at the discovery and preferred to be unresponsive to the claim lodged by the Complainant.

Now in the written version cum evidence on affidavit, the OP insurance Company claims referring to the terms and conditions of the policy that the insured in spite of being aware of the terms and conditions entered into one insurance contract, duly confirmed ‘his’ medical history in the proposal form and the insurance Company in good faith based on the declaration of the insured accepted the policy. The OP further claims that the insured suppressed the material facts relating to ‘his’ health.

But while repudiating the claim, OP 1 points at the Complainant’s mother’s health and her medical history who was not included in the policy.

OP 1 claims to have acted accordingly within the ambit of the norms and schedule of the policy and thus caused no deficiency in service.

It is noteworthy that while making their statement in the evidence on affidavit the word ‘his’ has been used twice while referring to medical history and material facts relating to health (Highlighted above).

From the above, it is apparent that the OP was also conscious enough that the policy is bothered only about medical history and material facts relating to health of the insured person only and not of his father, mother, grandfather, grandmother, great grandfather, great grandmother and so on.

So far as policy documents, its terms and conditions and other related documents furnished by the Complainant are concerned there was no suppression of medical history and material facts related to health on the Complainant’s part. The Complainant was under no obligation to mention the medical history of all the persons belonging to his family chain, while opting for the particular insurance policy.

Thus, the plea taken by the OP Insurance Company to repudiate the claim is ridiculous, hollow, baseless and at once mischievous. The only mission of the OP Insurance Company was to repudiate the claim by hook or by crook.

This Commission is compelled to say that the way in which the claim of the Complainant has been repudiated is highly deplorable. The basic trust of public in general, on these Insurance Companies is likely to be eroded to an alarming extent if claims are repudiated on such filmsy grounds. The question which will arise naturally that why are these medical insurances for. Are the Insurance Companies meant for realizing premiums only?   

            Considering the facts and circumstances of the case this District Commission draws the inference that there was grossly unfair attitude on the OP 1’s part in dealing with the Complainant’s claim. The OP Insurance Company desperately tried to find out an excuse to defeat the rightful claim of the insured by picking a stray reference from the medical records. Moreover, malaises of diabetes, hypertension, ischemia, anginal pain are controllable with medicines and are not such diseases non-disclosure of which may be used for repudiating a claim against mediclaim policy. These are normal wear and tear of human life. Above all in the instant case, there was no such pre-existing health problem with the insured person i.e. the Complainant.  

Hence, it is

                                                ORDERED

that the complaint case bearing no. 43 of 2018 be and the same is allowed on contest but in part.

The OP 1 i.e. National Insurance Company Ltd. is hereby directed to entertain the claim of the Complainant against the policy and reimburse medical expenses to the maximum possible extent within the ambit of the individual policy coverage. This reimbursement will be accompanied by 9% interest for the period from the date of sending the legal notice i.e. 03.03.2017 to the actual date of reimbursement of the medical expenses. Besides OP 1 will be liable to pay compensation to the extent of Rs.25,000/- for causing harassment, anxiety and mental agony and litigation cost to the tune of Rs.7000/-

OP 1 is hereby directed to comply with this order within 45 days from the date of this order failing which the Company will be liable to pay Rs.30,000/- to the Consumer Legal Aid Account.

Let a plain copy of this order be supplied free of cost to the parties/their Ld. Advocates/Agents on record by hand under proper acknowledgements/sent by ordinary post for information and necessary action.

The final order will be available in the respective website i.e. www.confonet.nic.in.