FINAL ORDER/JUDGMENT
SMT. SUKLA SENGUPTA, PRESIDENT
The complainant files the instant petition of complaint U/S 12 of the C.P. Act, 1986.
The fact of the case in a nutshell is that the complainant purchased a Health Insurance Policy from the OP-1 in the year 2012 for the benefit of his brother Debajit Tapadar being Policy No. 100300/48/13/8500005091. The photocopy of the Policy Certificate has been annexed with the petition of complainant as P-1.
It is further stated by the complainant that at the time of availing the insurance policy in question he narrated all facts about his brother’s the then existing diseases. The complainant claimed the medical expenses of his brother Debajit Tapadar who admitted in Nightingale Hospital and discharged on 23.11.2013. The matter was informed to the OP-1 and supplied several set of documents as per plaint of the OP-1. But on receipt of all the documents the Insurance Company did not response anything about the claim made by the complainant in respect of the policy in question.
The complainant then agitated the issue with the OP-1 through its Senior Executive who assured to look into the matter personally and several communication were made via E-mail, ultimately on 07.10.2016 the said Executive of the OP-2 repudiate the claim of the complainant via E-mail. The copy of which is annexed P-2 along with the petition of complaint. The claim of the complainant pertaining to Rs.30,000/- which is/was medical expenses borne by the complainant for treatment of the beneficiary of the policy in question. It is alleged by the complainant that the OP-1 caused deficiency in service on its part by repudiating the claim of the complainant and caused harassment and mental pain and agony to him.
It is the case of the complainant that he is entitled to get the medical expanses of Rs.30,000/- and also entitled to get Rs.1,00,000/- as compensation towards mental pain and agony and litigation cost.
The cause of action arose on 07.10.2016 at the office of OP-1 when the claim of the complainant was repudiated by the Executive of the OP-1. Hence, the instance case is filed by the complainant with a prayer to give direction to the OPs to reimburse the insurance claim of Rs.30,000/- in favour of the complainant along with interest from 28.08.2017 till the date of actual payment.
The complainant further prayed for giving direction to the OPs to pay a sum of Rs.30,000/- only and Rs.1,00,000/- towards litigation cost and compensation to the complainant for harassment, mental pain and agony.
The OP-1 has contested the claim application by filing Witten Version/Written Statement denying all the material allegations leveled against it.
Admittedly the complainant availed an individual Mediclaim Policy with the OP-1 for the benefit of his brother Debajit Tapadar being Policy No. 100300/48/13/8500005091. It is further stated by the OP-1 in his WV that the complainant lodged the claim under the policy in question seeking reimbursement of treatment cost of Rs.29,040/- on account of Mr. Debajit Tapadar, who was admitted to the Nightingale Diagnostic and Medicare Centre Pvt. Ltd. on 20.11.2013 and discharged on 23.11.2013 (Annexure-I). It is further stated by the OP-1 that the brother of the complainant was admitted for CVA (Aterio-venous Malformation – AVN), Hypokalemia as per discharged certificate dated 23.11.2013 issued by Nightingale Nurshing Home (Annexure-B). It is alleged by the OP-1 that as per initial assessment sheet of Nightingale Diagnostic Centre wherein it is mentioned that the brother of the complainant was an old case of AVN and he was treated since August, 2004 at AMRI Hospital. Copy of the initial assessment sheet has been annexed herewith as Annexure – C.
It is alleged by the OP-1 in his WV that the brother of the complainant had history of ICH and IVH due to rapture of (Aterio-venous) Malformation since 2004 as per previous treatment summery issued by AMRI dated 15.10.2004 (Annexure-D).
It is further alleged that the history of ICH (Intra Cerebral Hemorrhage and Intra Ventricular Hemorrhage (IVH) due to rapture of AV Malformation in August, 2004 of the brother of the complainant has not been disclosed at the pre acceptance record of the Policy. It is the case of the OP-1 that as per policy conditions under exclusion of Clause-4 of the Insurance Co. (OP-1) shall not be liable to make any payment under the policy in respect of the any expenses incurred by the policy holder in connection with or in respect of all pre existing disease when the cover incepts for the first time until 48 months of the continuous coverage has elapsed. The copy of the policy condition (Clause 4.1) is marked as annexure E. It is the case of the OP-1 that the petition of complaint is barred by limitation because the claim was repudiated in the year 2014 and the complainant was filed the case in the year 2018 that is beyond the limitation period of 2 year, the case is also suffering from non joinder and misjoinder of necessary parties thus the claim is not admissible due to non disclosure of pre existing disease and the petition is thus dismissed with cost.
In view of the above stated facts and circumstances, it has to be decided by this Forum:
- Whether the case is maintainable in its present form and in law?
- Is the case barred by limitation?
- Is the complainant a consumer?
- Is there any deficiency in service on the part of the OP members?
- Is the complainant entitled to get relief as prayed for?
Decision with reasons
All the points are taken up together for convenience of discussion and to avoid unnecessary repetition.
It is the case of the complainant that he purchased the insurance policy in question being Policy No. 100300/48/13/8500005091 in the year 2012 for the benefit of his brother Debajit Tapadar as shown in the policy certificate (P1). Thereafter the brother of the complainant was admitted at Nightingale Hospital and discharged on 23.11.2013. Then the complainant claimed medical expenses of Rs.30,000/- from the OP insurance Co. borne towards the medical expenses at Nightingale Hospital. But the said claim has been repudiated by the OP insurance Co. Heritage Health TPA Pvt. Ltd. vide its letter dated 18.08.2014 on the basis of the discharged certificate of Nightingale Hospital dated 23.11.2013 and previous treatment at AMRI hospital dated 15.10.2014.
Thereafter the complainant again agitated the issue with the OP-2 through its Senior Executive Officer and ultimately on 07.10.2016 the said Executive of the OP-2 informed the complainant that the claim has been repudiated owing to concealment of pre existing disease.
In this respect, the OP-1 in his WV as well as in his evidence stated that the complainant cannot get the claim as prayed for because from the Annexure-D the treatment summery issued by AMRI hospital dated 15.10.2004 it is palpably clear that on 08.08.2004 he was admitted at AMRI hospital with sudden onset headache followed by left side weakness and vomiting but no convulsion and he had history of febrile illness and on investigation it was detected that he has suffering from AVM (Aterio-Venus Malformation) and he was undergone surgery therein.
It is the further case of the OP that this matter of AVM was suppressed or concealed by the complainant at the time of initiation of the policy in question. So, the claim of the complainant is non-admissible and stands repudiated under Clause 4.1 of NIC individual mediclaim policy and the claim was repudiated by the OP Insurance Co. vide its letter dated 18.08.2014.
So, from the Annexure-A as submitted by the OP Insurance Co., it is palpably clear that the beneficiary of the policy in question that is Debajit Tapadar was seriously ill since long back of getting the policy in question by the complainant in the year 2012 for the medical treatment of Debajit Tapadar. The treatment summary of AMRI i.e. Annexure-D as filed by the OP along with their WV as issued by the AMRI Hospital dated 08.08.2004 it is found that Debajit Tapadar was suffering from ICH and IVH due to rapture of AV Malformation since long back of the date of obtaining the insurance policy by the complainant for his benefit in the year 2012 but that has not been disclosed to the OP Insurance Co. by Debajit Tapadar or by the complainant himself as the time of obtaining the Insurance Policy.
From the materials on record it appears that admittedly the complainant received the letter of repudiation from the OP-1 on 18.08.2014 at his residence and the cause of action arose since then. Subsequently, the complainant tried to save his case from limitation by filing an application for amendment dt. 20.11.2019 to amend the date of cause of action in his petition of complaint but the then Commission was pleased to reject the same vide its order dated 21.01.2020 observing that if the prayer of the complainant be allowed then the defense of the OP would be frustrated that the cases is barred by limitation. On the date of hearing of argument neither the complainant nor his conducting Advocate feel any urge to agitate the matter of limitation before this Commission.
However, on a close scrutiny of the materials on record and considering the position of law it is held by this Commission that in his petition of complaint the complainant admitted that the cause of action arose on 08.08.2014 when he received the letter of repudiation at his residence sent by the OP insurance Co. The materials on record shows that the case was filed by the complainant on 05.10.2018 long after the limitation period of filing the case. So the allegation of the OP insurance Co. as stated in his WV and documents that the case is barred by limitation is proved beyond reasonable doubt and after considering all the facts and circumstances and the materials on record it is held by the Commission that the case is barred by limitation.
On the basis of the discussions made above it is also held by this Commission that the complainant purchased the Health Insurance Policy in question for the benefit of his brother Debajit Tapadar but at the time of purchasing the Insurance policy in question he did not disclose to the OP-1 Insurance Co. about the pre existing disease of his brother so as per terms and condition of the health insurance policy in question the claim of the complainant rightly turndown by the OP-1 as non-admissible and stands repudiated under Clause 4.1 under NIC Individual Mediclaim Policy. Thus the complainant is not entitled to get the relief as prayed for.
In sum the complainant failed to file the case within the limitation period and also the case is suffering from suppression of materials facts in respect of pre existing disease of the beneficiary at the time of obtaining the health policy in question from the OP-1 thus, the complainant is failed to prove his case beyond the shadow of all reasonable doubt and is not entitle to get the relief as prayed for.
The case is properly stamped.
All the issues are thus decided accordingly as per discussions made above.
Hence,
ORDERED
that the Complaint Case be and the same is dismissed on contest against the OPs without any costs.
Let a copy of this order be handed over to the parties free of cost.
