In the Court of the
Consumer Disputes Redressal Forum, Unit -I, Kolkata,
8B, Nelie Sengupta Sarani, Kolkata-700087.
CDF/Unit-I/Case No. 218 / 2010.
1) Sri Sajjan Kumar Poddar,
12, Bamancharan Roy, Road, P.S. Behala, Kolkata-34. ---------- Complainant
---Versus---
1) National Insurance Co. Ltd.
3, Middleton Street, P.S. Shakespeare Sarani,
Kolkata-71 and having its Calcutta Divisional-IV office, at
B-2/1, Gillander House, 8, Netaji Subhas Road,
P.S. Hare Street, Kolkata-1.
2) Heritage Health Service Pvt. Ltd.
Represented by its Manager,
Nicco House, 5th Floor, 2, Hare Street, P.S. Hare Street, Kolkata-1. ---------- Opposite Parties
Present : Sri Sankar Nath Das, President.
Dr. Subir Kumar Chaudhuri, Member
Smt. Sharmi Basu, Member
Order No. 31 Dated 21/11/2012.
The petition of complaint has been filed by the complainant Sri Sajjan Kumar Poddar against the o.ps. National Insurance Co. Ltd. and others. The case of the complainant in short is that complainant is the husband and beneficiary of policy of the Kamala Devi Poddar (since deceased) and complainant’s wife Kamala Devi Poddar (since deceased) during her life time had taken Hospitalization benefit Policy in the year 2008 from National Insurance Co. Ltd. Division-IV for self bearing no.100600/48/078/850008185 was issued to her for the period from 31.3.08 to 30.3.09 and accordingly to the demand of o.p. no.1 she paid the premium of Rs.6045/-. Thereafter, complainant’s wife again renewed the said policy for 31.3.09 to 30.3.10 by paying the requisite premium Rs.6045/- for the same and accordingly o.p. no.1 issued a Hospitalization benefit Policy certificate bearing no.100600/48/078/850008102 for the said period. Therefore, it can be said complainant’s wife is covered in the Hospitalization benefit policy by o.p. no.1 since March, 2008.
On May, 2008 complainant’s wife had some problem of post menopausal bleeding and chronic endometriosis was investigated and properly diagnosed to be a casa of hysterectomy operation and was advised for early surgery by her physician. In January, 2009 wife of complainant started suffering from some bleeding problem and as per advice of doctor certain medical tests done and after obtaining the test reports as per advice of doctor went to Dr. Ashis Mukherjee of Netaji Subhas Chandra Bose Research Institute on 13.1.09 and after clinically examined by him complainant’s wife detected and confirmed by the said doctor as cancer patient and subsequently her treatment for cancer was started from 16.1.09 and continued till she died on 23.7.09. All the treatment papers and medical papers including bills, discharge summary and other medical reports submitted by her with the insurance company along with claim forms.
Complainant’s wife in terms of the Hospitalization benefit Policy duly filed a mediclaim form issued by o.p.no.1 for the period treatment from on 16.1.09 to 1.3.09 and deposited all the relevant papers on 18.3.09 and original bills amounting to Rs.77,207/- for the aforesaid treatment in respect of her claim and asked o.ps. to process her claim. Complainant’s wife received a letter dt.5.5.09 sent by Claim Executive of o.p. no.2 asking her to furnish discharge certificate of past hysterectomy operation. Thereafter, complainant’s wife in compliance said letter dt.5.5.09 sent the discharge certificate of past hysterectomy operation issued by Belle View Clinic by her letter dt.23.5.09 which was duly received by o.p. no.2 affixing it seal. Complainant’s wife in terms of the hospitalization benefit policy duly filed the second claim as per the mediclaim form issued by o.p. no.1 for the period treatment from on 14.4.09 to 8.5.09 and deposited all the relevant papers on 2.6.09 and original bills amounting to Rs.71.352/- for the aforesaid treatment in respect of her claim and asked o.ps. to process her claim.
Thereafter, to the complainant’s wife immense surprises she received a letter dt.11.6.09 from o.p. no.2 stating that the claim submitted by complainant has been found to be inadmissible as per terms and condition of mediclaim policy and the reason for such repudiation was Clause (4:3) Disease excluded in first two years of insurance. Hence the case was filed by complainant with the prayer contained in the petition of complaint.
O.p. no.1 had entered its appearance in this case by filing w/v and denied all the material allegations labeled against it and prayed for dismissal of the case. O.p. nos.2 and 3 did not contest the case b y filing w/v and matter has been heard ex parte against them. Ld. lawyer of of o.p. no.1 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 the husband and beneficiary of the policy of Kamala Devi Poddar since deceased and complainant’s wife is covered in the hospitalization benefit policy by o.p. no.1 since March, 2008 and complainant’s wife fell sick and was confirmed by the doctor as a cancer patient and treatment was started from 16.1.09 and continued and officially died on 23.7.09 and all the relevant papers were sent with the insurance company along with claim form twice and o.p. no.2 repudiated the mediclaim. Now on careful scrutiny of the record that there is no case that the insurance policy was invalid for non payment of premium and we do not find any earthly reason for such repudiation and this act on the part of o.ps. amounts to deficiency in service being service provider to their consumer / complainant and complainant is entitled to relief.
Hence, ordered,
That the case is allowed on contest with cost against o.p. no.1 and ex parte with cost against o.p. nos.2 and 3. O.ps. are jointly and/or severally directed to reimburse Rs.2,13,761/- (Rupees two lakhs thirteen thousand seven hundred sixty one) only for the treatment of the complainant’s wife together with interest @ 9% p.a. over the said amount from the date of repudiation till realization and are further directed to pay compensation of Rs.25,000/- (Rupees twenty five thousand) only for harassment and mental agony and litigation cost of Rs.5000/- (Rupees five thousand) only within 45 days from the date of communication of this order, i.d. an interest @ 9% 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.
