Judgment dated : 2.5.2016
This is a complaint filed by one Sri Debanagshu Dasgupta against National Insurance Ltd. and Heritage Health TPA Pvt. Ltd. praying for Rs.60,778/- and Rs.2,00,000/- for mental agony and harassment and also cost of the case.
Facts in brief are that Complainant took an Insurance Policy named Sampoorna Arogya Bima Policy being Policy No.10440/48/14/8500001857 by the OP Insurance Company and the sum assured was Rs.1,00,000/- which C.B.Amount of Rs.25,000/-.
Complainant has a sound health in all respect and was very much fit till the heart problem was detected on 18.12.2014 for which Complainant was admitted in S.S.K.M.Hospital under Dr.S. C. Mondal and was discharged from the hospital on 28.12.2014. After his unexpected heart surgery the expenditure during this period which Complainant incurred was Rs.1,27,892/-. After hospitalization the Complainant had communicated this fact to the OP on 23.12.2014. Complainant made a claim of Rs.1,27,892/- but OP reimbursed only Rs.26,050/-. Complainant made a claim of another Rs.60,778/- after deducting the amount as per terms of the insurance.
OP files written version where it has been submitted that Complainant had a mediclaim insurance with a sum assured of Rs.1,00,000/- and C.B. of Rs.25,000/-. It is also admitted that Complainant was treated at S.S.K.M. Hospital from 18.12.2014 to 28.12.2014. Complainant made a claim of Rs.1,27,892/-.
OP has submitted that Complainant had pre existing disease and the claim was restricted upto Rs.50,000/- on the policy which he had taken during 2008-2009. Further OP has stated that the claim has been settled on Rs.26,050/-.
On the basis of above facts following points were framed :
- That the OP were justified in depriving Complainant in not paying Rs.60,778/- and this is a deficiency in service ;
- That Complainant is entitled to reliefs as prayed for.
Decisions with reasons
Both the points are taken up together for brevity and convenience.
In this case Complainant has filed affidavit-in-chief and has stated facts mentioned in the Complaint. Further OPs has put ten questions to the Complainant and those have been answered by the Complainant. The answers to questions 2, 3 & 4 are in negative. In answer to question No.5 the Complainant has stated that he received Rs.26,050/-. Further he has denied that he had no pre existing heart desease. He has also admitted that Sampoorna Arogya Bima Policy has a locking period of five years for pre existing heart disease but in his case there was no question of locking period because he did not have any heart disease.
So, on the basis of the above facts it is clear that the dispute is around pre existing disease. It is clear from written version that Complainant had policy with the OP since 2008- 2009 and there is no whisper that Complainant received any amount from the insurance company for the last five years. If we take the policy year from 2008, five years get completed in a policy which Complainants took in the year 2013 – 2014. So, by no stretch of imagination it can be said that locking period of five years is applicable here because Complainant received the money for a policy of the year 2014 – 2015 on 17.12.2015.
The next significant question is whether OPs have right to deprive a person of his claim on the basis of mediclaim insurance policy on the ground that the person has pre existing disease.
In our view it is the duty of the insurance companies while accepting premium from senior citizen to test health check up thoroughly which they do and also after that they issued the policy. The duty of the senior citizen is not that he is aware of the disease which he might be afflicted. So, once the policy is issued the pre existing disease should not be taken while settling the claim of the person concerned who remains hospitalized for 10 – 15 days.
The question of ascertaining the pre existing disease can never be on the insured and the obligation is upon those who received the premium that is insurer.
In the aforesaid facts and circumstances we are of the view that Complainant has been unnecessarily harassed by the OPs in not paying his genuine claim.
Hence,
O R D E R E D
Opposite Parties are directed to pay Rs.60,778/- to the Complainant within two months of this order, of course on submission of original vouchers before the insurance company. Further, OPs are directed to pay compensation of Rs.30,000/- for harassment of Complainant and Rs.10,000/- as litigation cost within the same period.
We make it clear that if the ordered amount is not paid within the period, those shall carry 10% interest from the date of order till realization.
Accordingly, CC/71/2015 stands disposed off.
