In  the  Court  of  the

Consumer Disputes Redressal Forum, Unit -I, Kolkata,

8B, Nelie Sengupta Sarani, Kolkata-700087.

CDF/Unit-I/Case No.19/2008

1)         Shri Animesh Halder and

Smt. Papiya Halder

112, Baithakkhana Road,

P.O. Raja Ram Mohan Sarani,

P.S. Amherst Street, Kolkata-700009                                         ---------- Complainants

---Versus---

1)         National Insurance Co. Ltd.,

Represented by its Divisional Manager,

Division No.XIV, 7, Council House Street,

4th Floor, PO. GPO, P.S. Lalbazar, Kolkata-700001.

2)         Family Health Plan Ltd.,

Represented by its authorized signatory

CRM Department, 16/2, Lake View Road,

PO. Sarat Bose Road, PS. Lake, Kolkata-700029                   ---------- Opposite Parties

3)         The Peerless Hospital & B.K. Roy Research Centre,

            Represented by Deputy Medical Supdt.

            360, Panchansayar , Kolkata-94                               ---------- Proforma Opposite Party         

Present :          Sri Sankar Nath Das, President.

                        Dr. Subir Kumar Chaudhuri, Member

                        Smt. Sharmi Basu, Member

Order No.   41    Dated  27/09/2012.

            The petition of complaint has been filed by the complainants Shri Animesh Halder and Smt. Papiya Halder against the o.ps. National Insurance Co. Ltd and others. The case of the complainants in short is that complainants are joint policy holder with one Arnab Halder i.e. son of complainant no.2 and brother of complainant no.1 for mediclaim under the National Insurance Co. Ltd. with third party coverage (i.e. Family Healthy Plan Ltd. who is the o.p. no.2 of this complaint) vide Policy number 103000/48/06/8500001006 for the period 28.6.06 to 27.6.07 and total sum insured of Rs.8 lakh and total basic premium is Rs.11,466/- with a family discount of Rs.900/-. But the net premium is Rs.10,566/- and service tax Rs.1293/- i.e. total sum paid as premium  Rs.11,859/-.

            Complainant no.2 was admitted in o.p. no.3 hospital on 4.12.06 for replacement of her left knee and the doctor treated complainant no.2 in the said hospital as indoor patient was Dr. Prabir Kumar Banerjee and the said operation was held on 6.12.06 and she had to undergo treatment from 4.12.06 to 19.12.06 including the holding of operation on 6.12.06 and she was discharged from the said hospital on 20.12.06. The insurance coverage was from 28.6.06 for one year and so the medical claim is well within the ambit of mediclaim of o.p. no.1. Complainant no.2 had to spend Rs.2,21,026/- for her treatment including the operation charges etc. in o.p. no3 hospital.

            Complainants submitted application annexing the original necessary medical papers and documents to the Divisional Manager, National Insurance Co. Ltd. Divison No.XIV for reimbursement of expenses of the treatment which was received by o.p. no.1 on 3.1.07  but it was repudiated by o.p. on the ground of clause no.4.1 of insurance i.e. pre-existing disease. Hence the case.

            O.p.1 had entered its appearance in this case by filing w/v and denied all the material allegations labeled against it. O.p. nos.2 and 3 did not contest the case and matter has been heard ex parte against o.p. nos.2 and 3. It is seen from w/v that the instant case has got no merit at all since the documents have been manufactured for the purpose of grabbing insurance amount and is liable to be dismissed.

Decision with reasons: -

            We have gone through the pleadings of the parties, evidence and documents in particular and nowhere we find that complainants were defaulter in the matter of making payment of premium of the policy in question and complainant no.2 had to undergo knee operation and complainants had to incur a sum of Rs.2,21,026/- for her treatment including operation charges etc. in the o.p. no.3 hospital and o.p. no.1 repudiated the claim on the ground of clause no.4.1 insurance policy. It is settled principle of law that insurance company cannot repudiate any claim on flimsy ground referring clause no.4.1 of insurance policy and it is fact that one is not supposed to know for which ailment he has been suffering and it is the duty of insurance company to get the insured examined by their panel doctor prior to filling up insurance contract form at the time of prior to insurance. So the act of repudiation on the part of o.ps. amounts to gross negligence being a service provider to its consumers / complainants and complainants are entitled to relief.

            Hence, ordered,

            That the petition of complaint is allowed on contest with cost against o.p. no.1 and ex parte with cost against o.p. nos.2 and 3. O.p. nos.1,2 and 3 are jointly and/or severally directed to pay Rs.2,21,026/- (Rupees two lakhs twenty one thousand twenty six) only being the medical expenses together with interest @ 9% p.a. from the date of repudiation  till the date of realization and are further directed to pay compensation of Rs.20,000/- (Rupees twenty 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.