Biswanath Pal,

s/o. late B. Pal,

village – Rabindranagar, P.O. Unsani, P.S. Jagacha,

District –Howrah,

PIN – 711302.-------------------------------------------------------------------  COMPLAINANT.

-          Versus   -

1.         National Insurance Co. Ltd.,

            3, Middleton Street,

            Kolkata – 700001.

2.         Manager / Authorized Person

            representing National Insurance Co. Ltd.,

            1/1, Camac Street, P.S. Park Street,

            Kolkata – 700016.

3.         Med Save Health Care ( TPA ) Ltd.,

            A.K. Trade Centre Pvt. Ltd.,

            1/1, Camac Street, P.S. Park Street,

            Kolkata – 700016.

4.         Manager /  Authorized person

            representing National Insurance Co. Ltd.

            Howrah Branch, 22,  G.T. Road ( South ),

            District – Howrah,

            PIN – 711101.------------------------------------------------------OPPOSITE PARTIES.

                                                P   R    E     S    E    N     T

President     :     Shri T.K. Bhattacharya, M.A. LL.B. WBHJS.

Member      :      Shri P.K. Chatterjee.

Member       :     Smt. Jhumki Saha.

                                                 F  I   N   A    L       O   R   D    E     R

1.                  Complainant, Sri Biswanath Pal,  by filing a petition U/S 12 of the C .P. Act,

1986 ( as amended up to date ) has prayed for a direction to be given upon the o.ps. to reimburse Rs. 61,317/- with interest @ 12% p.a., to pay Rs. 25,000/- in total as compensation for causing mental and physical harassment along with Rs. 2,000/- as litigation costs.

2.                  Brief facts of the case is that complainant purchased one medi claim policy

from O.P. nos. 1, 2 & 4 through O.P no. 3 on payment of required premium of Rs. 3,393/- for sum assured amount of Rs.2,00,000/-. That policy remained valid from 21-06-2012 to 20-06-2013 vide  Annexures 1 & 2. During that policy year, he was admitted to hospital on 20-10-2012, where after medication, operation was done and he was released from hospital on 31-10-2012 vide Annexure discharge summary.  Thereafter, he submitted claim form to O.P. no. 3 on 21-11-2012 with all details. But as his claim amount was not being paid by the O.Ps., complainant wrote a letter to O.Ps. on 28-01-2013 with the request to make the early payment of his claim, which was received by O.Ps. vide Annexure 3. But O.Ps. remained silent. So, again on 12-02-2013 complainant sent one letter to O.Ps.  through post office vide Annexure 4. But till the filing of this case, complainant did not get his legitimate claim of Rs. 61,317/-. Being aggrieved and finding no other alternative, complainant filed this instant petition praying for the aforesaid relief.

3.                  Notices were served. O.p. nos. 1, 2, 4 appeared and filed written version.

Accordingly, the case was  heard ex parte against O.P. no. 3.

4.                  Upon pleadings of both parties two points arose for determination :

i)          Is there any deficiency in service on the part of the O.Ps.  ?

ii)                  Whether the complainant is  entitled to get any relief as prayed for ? 

DECISION  WITH   REASONS      :

5.                  Both the points are  taken up together for consideration.            O.Ps. in their written

version have taken a specific plea that as the complainant took the medi-claim policy in question for the 1^st time on 21-06-2012 and the hospitalization took place in the very 1^st policy year i.e., in between 20-10-2012 to 31-10-2012. And as per the policy condition no. 4.3, the diseases like BPH ( Benign Prostatic Hyperthropathy ) is not covered under the policy in question. And as per discharge summary given by the hospital, complainant was having BPH, Dyslipidemia with diabetes mellitus. So, according to O.Ps. complainant is not entitled to any reimbursement. But no document in support of these contention, O.Ps. could submit. Moreover, when complainant took the policy in the year of 2012, he was 60 year old person but O.Ps. did not ask him to undergo any  medical investigation before the initiation of such policy. At the  time of receiving premium, O.Ps. are very liberal but they are very tough at the time of giving claim amount. These exclusion clauses are nothing but are designed to harass the policy holders. Ours is a welfare state. And each and every insurer has a social obligation towards its insured. Any vague plea taken by O.Ps. should not be allowed. O.Ps. have also admitted the fact of hospitalization of the complainant and have not denied the medical expenditure of Rs. 61,317/-.  So, the claim of the complainant is also legitimate and bonafide. Mediclaim policy is always made for one year and subsequent renewal of the said policy makes it a continuous one. If a person does not pay the renewal premium, it lapses. Under the said premises, each policy year is the first year for a particular mediclaim policy. So, in the first year due so some exclusion clause, ‘claim cannot be allowed’, O.P.’s this plea is not at all tenable in the eye of law. Even after paying the premium, O.P.’s this kind of attitude towards the complainant, is nothing but gross negligence in discharging duties towards the complainant. It has become a very common experience for the Consumer Forum. In this case, O.Ps. have not even sent any repudiation letter to the complainant. He was also passing through tremendous mental pain. O.Ps. are expected to be more careful about their policy holders when they are entering into a contract of indemnifying the medical expenses incurred by the policy holders. But they have neglected their duty. Accordingly, O.Ps. are found to be deficient in rendering service towards the complainant. 

Points under consideration are accordingly decided.

      Hence,

                                    O     R     D      E      R      E        D

      That the C. C. Case No. 205 of 2013 ( HDF 205 of 2013 )  be  allowed on contest against O.P. nos. 1, 2 & 4 with  costs  and ex parte against the O.P. no. 3 with costs.  

      That the  O.Ps. are jointly and severally directed to reimburse Rs. 61,317/- being the amount of  medical expenses within 30 days from the date of this order.

      That the o.ps. are further directed to pay an amount of Rs. 10,000/- as compensation and Rs. 3,000/- as litigation costs to the complainant within one month from the date of this order.

      That the O.Ps. are directed to pay the entire amount of Rs. 74,317/- within one month, i.d., the entire amount shall carry an interest @ 10% p.a. till actual realization. 

      The complainant is at liberty to put the decree into execution after expiry of the appeal period.

      Supply the copies of the order to the parties, as per rule.            

DICTATED  &    CORRECTED

BY   ME.  

      (  Jhumki Saha  )                                                                  

  Member, C.D.R.F.,Howrah.