West Bengal

South 24 Parganas

CC/410/2014

Dr. APARNA DAS MAJUMDER, W/O Mrityunjoy Das Majumder - Complainant(s)

Versus

NATIONAL INSURANCE CO. LTD. - Opp.Party(s)

27 May 2015

ORDER

DISTRICT CONSUMER DISPLUTES REDRESSAL FORUM

SOUTH 24 – PARGANAS , JUDGES’ COURT, ALIPORE KOLKATA-700 027

 

              C.C. CASE NO. _410_ OF ___2014___

 

DATE OF FILING : 8.9.2014                                                                             DATE OF PASSING JUDGEMENT:  27.5.2015__

Present                                :   President       :   Udayan Mukhopadhyay

                                                    Member(s)    :    Mrs. Sharmi Basu

                                                                                                     

COMPLAINANT                       :    Dr. Aparna Das Majumder,w/o Mrityunjoy Das Majumder                                                  of 320, Netaji Subhas Chandra Bose Road, P.S. Netaji Nagar, Kolkata – 47.

• VERSUS  -

 

O.P/O.Ps                                    : 1.    National Insurance Co. Ltd. 3, Middleton Street, Kolkata – 71.

2.     The Divisional Manager, National Insurance Co. Ltd. Kolkata Division Office  XX, 6^th Floor, Jeevan Sudha Building, 42C, J.L. Nehru Road, Kolkata – 71.

3.     Asstt. General Manager, Mediclaim Mgmt. & Claims, Family Health Plan (TPA) Ltd. 1^st Floor, 16/2, Lakeview Road, Kolkata – 29.

___________________________________________________________________________________________

                                                                                J  U  D  G  E  M  E  N  T

Sri Udayan Mukhopadhyay, President                                    

The complainant’s case in short is that complainant filed one application under section 12 of the C.P Act, 1986 on the ground that complainant is a beneficiary of one Mediclaim Policy obtained by her husband on 16.8.2005 from the O.P-1 along with her  son ,wherein  her husband was a proposer. It has further stated that policy has been renewed uninterruptedly  till date and pay yearly premium as asked by the O.P-1 and lastly renewed on 14.8.2013 vide Policy number 101800/48/13/8565000068 valid from August 17,2013 to August 16,2014 . It has claimed that within the coverage period complainant was having urinal incontinence and hematuria and treated by Dr. S.M. Kumar and underwent various tests and thereafter she visited Rabindranath Tagore International Institute of Cardiac Sciences for better treatment and was admitted therein from 28.8.2013 to 30.8.2013 , wherein cystoscopy with vaginal mass biopsy were done. Hospital raised bill amounting to Rs.18,695/- out of which cashless amount of Rs.12,780/- was sanctioned by the O.P-3 and complainant had to pay the balance of Rs.5,915/- to the Hospital. It has stated that the report of Biopsy was “Adenocarcinoma, poorly differentiated (grade3) i.e. cancer.  It has further stated that wife of the complainant was taken to the Saroj Gupta Cancer Centre and Research Institute on 9.9.2013  for further treatment under Dr. Subhasish Dey , a Gynecological Oncologist  and after examination he suggested some tests to determine the line of treatment and it was decided by the board of doctors that radiotherapy for four and half weeks with concurrent chemotherapy from OPD and thereafter a Brachytherapy once in a week  for two weeks is required to be given. Complainant paid initially Rs.10,000/- to start the treatment and contacted corporate help desk of the hospital and informed them about the mediclaim facility ,who contacted the O.P-3 for cash less sanction and on the next date initial amount of Rs.32,900/- was approved by the O.P-3 and thereafter treatment was started. It has further stated that after completion of chemotherapy and radiotherapy Brachytherapy was given to her and for which necessary charges of Rs.9000/- was required to be paid by the complainant and undergo some pathological tests as per advice of the doctors. Thereafter hospital raised total bill amounting to Rs.76,758/-  and requested the O.P-3 for its sanction but subsequently O.P-3 only as a full and final settlement of the claim sanctioned Rs.37,449/-  and the rest amount had to be borne by the complainant. Thereafter, the complainant filed reimbursement claim on 23.12.2013 totaling to Rs.63,769/- to the O.P-3 and requested for its sanction. The O.P-3 flatly refused to sanction the same as per instruction of National Insurance Co. Ltd. And stated the reasons that already 50% of the sum assured exhausted in view of clause 1C . But the complainant has claimed that there is no terms and condition in the policy itself regarding 1C which was supplied to the complainant   because the copy of National Mediclaim Policy was only sent to the complainant. Hence, the complainant compelled to file this case with a prayer to direct the O.Ps to reimburse Rs.41,011/- plus interest @12% p.a and compensation to the tune of Rs.50,000/- and again compensation of Rs.50,000/- for mental agony and litigation cost of Rs.20,000/- as well as direction to return all original documents namely prescription, Pathology Test reports, etc. as mentioned in schedule C of the application.

                O.P-3 inspite of serving summon did not appear for which the case is running against him exparte.

                Practically O.P nos. 1 and 2 National Insurance Company contested the case and O.P-3 is TPA.

                The  O.P nos. 1 and 2 filed written version and have denied all the allegations leveled against them. It is the positive case of the contesting O.Ps that complainant’s husband had obtained a medical policy upon signing the proposal Form on 11.8.2011 from O.P-2 to cover himself, his wife and his son and renewed the same by paying total annual premium of Rs.8865/-  for the period of 17.8.2013 to 16.8.2014.

                It is the further case of the O.P that within the period of coverage the complainant has been diagnosed as ‘CA Vault of Vagina’  and admitted into SGC Centre and Research Institute on 20.9.2013 and discharged on 8.11.2013 and submitted her claim form claiming Rs.76,758/- which has been settled by the company to Rs.37,449/- and paid to the insured but the claim of Rs.63,769/- submitted by the insured for the same treatment has been repudiated by the O.P-3 TPA appointed by them vide its letter dated  25.1.2014 on the ground that “the member has exhausted considering the sub-limit under clause 1( C ) (50% of S.I) for the present ailment and does not have any balance in claim. It is the positive  case that under clause 1C of the policy the complainant insured has already availed towards the claim-settlement of Rs.4591/- (under claim id 420676), Rs.7960/- (under claim id 440479)  and Rs.37,449/- (under claim id 450773) totaling to Rs.50,000/- and as a result the complainant insured has enjoyed the maximum eligible  limit i.e. 50% of the sum assured ( Rs.1 lac) as enshrined under clause 1( c ) of the Policy ,for which TPA rightly rejected the claim amount of Rs.63,769/-. Accordingly there is no deficiency in service and unfair trade practice as alleged against the O.Ps. It is further stated that O.P Insurance Company being a Government Organization is not having any personal grudge upon the complainant ,rather provided or extended its full cooperation and sincere efforts towards the service of the complainant. Thus the allegation is baseless ,arbitrary, false and not sustainable in the eye of Law. Hence, O.Ps pray for dismissal of the case.

                Points for decision in this case is whether there is any deficiency in service or unfair trade practice on the part of the O.Ps.

 

Decision with reasons

                The moot question is whether Clause 1C  was inserted in the policy form supplied to the complainant. Since it is the case of the complainant that they are not aware regarding Clause 1C, wherein provision is that 50% of sum insured for the present ailment and does not have any balance in claim from Annexure M1 which has been filed by the complainant and definitely received from the O.Ps i.e. the policy namely National Mediclaim policy, wherefrom at page 3 we find from clause no.2 . 30 in the remarks column that maximum limit under section 2.3 for any one’s illness 50% of the sum insured. From the series of illness suffered by the complainant falls.

                So, at a glance 50% of sum insured is applicable. But thereafter it has been mentioned with a head note “Sub limit (as mentioned in 2.12.2 and 2.3) will not apply in case of (i) hospitalization in a preferred procedure Network(PPN) , (ii)  Ayurveda and Homeopathy treatment.

                Here in the instant case  clause 2.3 is there. So, that limit will not apply because complainant was admitted in a hospital of Dr. Saroj gupta Cancer Centre and Research Institute. But from the Policy as submitted by the O.P National Insurance Co. we find that the conditions are not identical with the policy condition handed over to the complainant. In the policy condition submitted by the O.P wherein we find that clause 1C is there where maximum limit per illness- 50% of sum insured but that condition will not be accepted by this Forum since the same was not unfolded to the complainant at the time of obtaining the policy . But inspite of that  different conditions which we have stated above has been given, that is why innocent complainant filed the claim application after treatment of his wife to the O.P and O.P repudiated the same on the ground of Clause 1C which is arbitrary and new thing to the complainant. So, that repudiation is not justified and complainant definitely should get total sum insured in relates to her ailment. Thus the repudiation letter dated 25.1.2014 is very much unfair and glaring example of deficiency of service . It may be mentioned here that O.P has relied the reported decision of 2013(2) CPR 143 passed by the Hon’ble National Commission , wherein Hon’ble national Commission has specifically mentioned the terms of policy  have to be construed as it is . But this judgement will not be helpful to the O.P since terms and conditions of the policy which is lying in the hand of the O.P has not been delivered.  So until and unless O.P has proved that the terms and conditions already delivered and complainant having knowledge of that terms and conditions of the policy , in that event the judgement of the Hon’ble National Commission as stated above will not be applicable and we may consider that the facts and circumstances of the judgement is not identical with the case in hand. We find from the case of the complainant that the complainant already received Rs.12,780/- from O.P-3 and further O.P-3 has sanctioned as full and final settlement of the claim Rs.37,449/-. Thus total amount comes to Rs.50,229/- in continuous treatment of Dr. Aparna Das Majumder. We are aware that sum insured is Rs.1 lac and on the basis of the same premium is being paid. We are also aware that complainant’s treatment was going continuously and when she was admitted at Rabindranath Tagore International Institute of Cardiac Science, she has to bear total charges Rs.18,695/- ,wherein O.Ps sanctioned Rs.12,780/- and remaining amount of Rs.5915/- have been paid by the complainant. Thereafter when cancer was detected she was compelled to admit Saroj Gupta Cancer Hospital , wherein the final bill was Rs.76,758/- and O.Ps have given Rs.37,449/-. Thus the total bill was Rs.95,453/- ( Rs.76758/- + Rs.18,695/-) which is less than the sum assured and in both cases complainant was hospitalized . But O.Ps only sanctioned Rs.12,780/- and Rs.37,449/-. We have already stated that clause 1C was not applicable to the complainant by saying latest mediclaim insurance policy (Individual) and it was the duty of the O.P to intimate to the complainant when policy was renewed- but inevitable did not happen. Behind the back O.Ps cannot impose any arbitral condition like 1C which goes against the interest of the complainant/insured. So, that should be brought to the knowledge of the complainant/insured and that is unfairness and unfair trade practice and that hide and seek terms and conditions should not be welcomed sitting in a chair of Forum.

                As per prayer of the complainant she will get Rs.41,011/- towards reimbursement claim along with compensation of Rs.20,000/- and litigation cost of Rs.5000/- and also to return the original documents namely prescription, pathological test report etc. as mentioned in Schedule C of the Application.

                Hence,

                                                                                                Ordered

That the application under section 12 of the C.P Act is allowed on contest against the O.P nos. 1 and 2 , and exparte against the O.P-3.

O.P nos. 1 and 2 are directed to pay Rs.41,011/- to the complainant within 45 days from the date of this order ,failing which interest will carry @9% p.a till its realization from the date of this order.

O.P nos. 1 and 2 are further directed to pay compensation of Rs.50,000/- and litigation cost of Rs.  5000/- within the stipulated period of 45 days from the date of this order and further directed to return all original documents like Prescriptions, Pathological Test Reports, which have been mentioned in the Schedule  of the complaint within that period, failing which complainant will also be entitled to get further interest @9% p.a on the total sum as stated above and Rs.25/- per day towards penalty for non-supply of the original documents and that penalty amount will be deposited to the Consumer Legal Aid Fund.

Let a plain copy of this order be served upon the parties free of cost.

 

                                                                                                Member                                                                              President

Dictated and corrected by me

 

 

                President

 

 

 

 

 

 

 

 

 

The judgement in separate sheet is ready and is delivered in open Forum. As it is ,

Ordered

That the application under section 12 of the C.P Act is allowed on contest against the O.P nos. 1 and 2 , and exparte against the O.P-3.

O.P nos. 1 and 2 are directed to pay Rs.41,011/- to the complainant within 45 days from the date of this order ,failing which interest will carry @9% p.a till its realization from the date of this order.

O.P nos. 1 and 2 are further directed to pay compensation of Rs.50,000/- and litigation cost of Rs.  5000/- within the stipulated period of 45 days from the date of this order and further directed to return all original documents like Prescriptions, Pathological Test Reports, which have been mentioned in the Schedule  of the complaint within that period, failing which complainant will also be entitled to get further interest @9% p.a on the total sum as stated above and Rs.25/- per day towards penalty for non-supply of the original documents and that penalty amount will be deposited to the Consumer Legal Aid Fund.

Let a plain copy of this order be served upon the parties free of cost.

 

                                                                                                Member                                                                              President