Consumer Complaint No. 64 of 2016
Date of filing: 11.4.2016 Date of disposal: 17.01.2017
Complainant: Mohanananda Goswami, S/o. Sri Nityananda Goswami, resident of Kalna Kasaipara, Opposite of Bank of Baroda, PO. & PS: Kalna, District: Burdwan, Pin – 713 409.
-V E R S U S-
Opposite Party: 1. National Insurance Co. Ltd., Memari Branch, represented by its Branch Manager, having its office at G. T. Road, Puspanjali Market, Memari, Opp. Memari P.S. District: Burdwan, PIN – 713 146.
2. Medi Assist India (TPA) Pvt. Ltd., represented by its Manager, having its office at 4, “Premier Court”, 4th Floor, 4, Chandni Chowk Street, Kolkata – 700 072.
Present: Hon’ble President: Sri Asoke Kumar Mandal.
Hon’ble Member: Smt. Silpi Majumder.
Hon’ble Member: Sri Pankaj Kumar Sinha.
Appeared for the Complainant: Ld. Advocate, Suvro Chakraborty.
Appeared for the Opposite Party No. 1: Ld. Advocate, Shyamal Kumar Ganguli.
Appeared for the Opposite Party No. 2: None.
J U D G E M E N T
This complaint is filed by the Complainant u/S. 12 of the Consumer Protection Act, 1986 alleging deficiency in service, as well as, unfair trade practice against the OPs as the OPs did not decide his legitimate insurance claim (medi-claim) till filing of this complaint.
The brief fact of the case of the Complainant is that in the year 2010 he obtained a medi-claim policy from the OP-1 after making payment of Rs.5, 469=00 towards premium and accordingly the OP-1 issued the policy in his favour, which was valid for the period from 30.11.2010 to 29.11.2011. The said policy is continuing without any interruption and the Complainant is using to pay exact premium for the said policy till date. The policy coverage is for Rs.3, 50,000=00 regarding any injury and/or hospitalization of the insured as per the terms and conditions of the policy. The said policy was renewed time to time and lastly it was renewed for the period from 30.11.2013 to 29.11.2014. During validity of the policy the Complainant became ill due to his abdominal pain and for this reason he consulted Dr. P.K. Sethy of medical Superspeciality Hospital, Kolkata on 05.05.2014. The Complainant was treated therein up to 08.05.2014 and for this treatment he incurred expenses to the tune of Rs.18, 520=00. As the abdominal pain has not been cured as per the advice of the said doctor he took admission at the said hospital on 23.07.2014 and got discharge therefrom on 26.07.2014. During this time he incurred expenses towards his medical treatment for Rs.18, 368=00. Inspite of such prolonged treatment his pain in the abdomen was not removed and as such he got admission further at the same hospital on 28.07.2014 as per the advice of the treating doctor and got discharge on 31.07.2014 and he incurred treatment cost for Rs.15,640=00. Due to his ill luck he begun to suffer from abdominal pain again from the 2nd week of August, 2014. He consulted with the treating doctor and as per his advice he got admission at the same hospital on 18.08.2014 and his treatment was continued till 22.08.2014 and during this period he had to bear treatment cost of Rs.24,104=00. After taking discharge from the hospital he intimated the OPs regarding his hospitalization through the authorized agent of the OP-1. Upon getting information the OPs issued claim form in favour of the Complainant and the Complainant accordingly submitted the filled up claim form along with all the relevant papers and documents in original before the OP-2 on 08.12.2014. But after receipt of the same the OPs instead of settling the claim, kept themselves silent over the matter. The Complainant through the authorized agent requested the OPs on several times, but he did not get any relief. The Complainant all on a sudden on 20.12.2014 came to learn from the authorized agent of the OP-1 that the OP-2 by sending a mail has asked for some clarifications and documents from him. After getting the printed copy of the said e-mail the Complainant submitted the required documents and proper clarifications of the queries of the OP-2 on 22.01.2015 and the OP-2 had duly received the same. The OPs were asked by the Complainant to settle his claim as early as possible. But as the OPs kept themselves silent regarding settlement of his claim, he submitted written representation before the OP-1 & 2 on 16.11.2015 and 18.11.2015 respectively through the authorized agent of the OP-1. But the OPs were reluctant to settle the claim of the Complainant. As the Complainant was at bed rest as per the advice of his treating doctor he made all correspondences through the authorized agent of the OP-1. As the OPs did not settle his claim and kept it pending for a prolonged period, hence having no alternative the Complainant has approached before this Ld. Forum by filing this complaint praying for direction upon the OPs to make payment of Rs.76, 632=00, towards treatment expenses, Rs.50, 000=00 as compensation due to mental pain, agony and harassment and litigation cost of Rs.20,000=00 to him.
The petition of complaint has been contested by the Op-1 by filing written version contending that the Complainant was enjoying hospitalization benefit policy and total sum assured was of Rs.3,40,000=00 held with the OP-1 for the policy period from 30.11.2010 to 29.11.2011, 30.11.2011 to 29.11.2012, 30.11.2012 to 29.11.2013 & 30.11.2013 to 29.11.2014. During policy period the Complainant suffered from abdominal pain and for which he was in the hospital for the period from 05.05.2014 to 08.05.2014 and incurred treatment cost for Rs.18, 520=00. In the claim form the date of treatment was not mentioned and many columns were not filled up properly. The Complainant got admission at the same hospital on another three occasions and incurred expenditure to the tune of Rs.18, 368=00, Rs.15, 640=00 & Rs.24, 104=00. After getting release the Complainant lodged the claim form claiming Rs.58, 112=00, but the claim form was incomplete. He submitted the form through the agent of the OP-1 and the OP-2 being the TPA advised the agent of the OP-1 to provided proper and valid reasons for late submission of claim documents, exact reason of pancreatitis certified by the treating doctor, history sheet, admission form, continuation sheet and treatment related papers certified by the hospital authority. From the certificate issued by the Dr.P.K. Shethy of Medica Superspeciality Hospital under whom the Complainant was treated that the patient was again treated from 25.12.2014 to 28.12.2014 with acute pancreatic pain. Complainant on 21.01.2015 informed the Senior Branch Manager of the OP-1 that due to his illness he could not submit the claim form in time for which he offered excuses. The Complainant also authorized the OP-2 to collect indoor case papers, history sheet, admission form, continuation sheet from Medica Superspeciality Hospital. Upon receipt of those documents the OP-2 by issuing a letter dated 24.03.205 gave intimation to the Complainant of such receipt and also stated their inability to admit the liability due to some reason i.e. in terms of the clause no-4.2.1 the OP-1 shall not be liable to make any payment under the policy in respect of any expenses incurred in connection with or in respect of following disease/treatment for:-‘ treatment arising out of illness/disease/injury due to misuse or abuse of drugs/alcohols or use of intoxicated substances.’ The observation of OP-2 was ‘on perusal of above claim documents it is observed that the patient was treated for recurrent acute pancreatitis/htn/dm from 23.07.2014 to 22.08.2014. It is evident that the patient had alcoholic consumption and there is permanent exclusion for treatment of disease arising out of use alcohol in policy. Hence the claim is not admissible as per the policy clause mentioned. Hence we regret our inability to admit this liability under the present policy condition. You still have the right to appeal to the insurer.’ In a letter date 26.11.2013 the OP-2 intimated the OP-1 regarding their recommendation of denial of the claim with the remark i.e. ‘this is a case of acute pancreatitis, hypertension and diabetes mellitus. As per indoor case paper and bed head tickets dated 30.07.2015 there is a history of alcohol consumption and duration of hypertension and diabetes is for last 10 years, hence denied the claim as per the exclusion clause 4.8 & 4.1 of the terms and conditions of the concerned policy as the policy is running in the 3rd year. Hence the claim may be repudiated.’ On the basis of the recommendation of the OP-2 and due to violation of the terms and conditions of the policy the claim of the Complainant was repudiated and moreover before completion of continuous four years of the policy since its inception the insured is not entitled to get any reimbursement towards the treatment expenditure in connection with the pre-existing disease/sickness/injury. According to the OP-1 as there is no deficiency in service as well as unfair trade practice on its part, hence the complaint is liable to be dismissed.
The Complainant by filing a petition on 12.08.2016 had prayed for treating his petition of complaint as his evidence on affidavit and accordingly the same is treated as his evidence as the petition of complaint filed on affidavit. The OP-1 has adduced evidence on affidavit. Both parties have filed some papers and documents in support of their respective contentions. The ld. Counsel for the Complainant has relied on some rulings in favour of his complaint.
It is evident from the record that inspite of receipt of notice the OP-2 did not turn up to contest the complaint either orally or by filing written version, so the complaint is running ex parte against the OP-2. On the date of the final argument none was present on behalf of the OP-2, so we took up the argument ex parte against the OP-2.
We have carefully perused the record: papers and documents filed by the contesting parties and heard argument at length advanced by the Ld. Counsel for the parties. It is seen by us that admittedly the Complainant purchased medi-claim policy from the OP-1 in the year 2010, due premium was paid continuously, the policy was renewed from to time without any break, during validity of the policy the Complainant became ill, went to the doctor of the Medical Superspeciality Hospital on 05.05.2014, got discharge on 08.05.2014, incurred medical expenditure to the tune of Rs.18,520=00, thereafter he again took admission at the same hospital under the same doctor on three occasions, lastly he got discharge on 22.08.2014, after getting discharge the Complainant lodged the claim form along with relevant treatment related papers claiming a sum of Rs.58,112=00 under the medi-claim policy. The allegation of the Complainant is that since filing of the claim form the Insurance Company did not decide his claim till filing of this complaint and such inaction of the OP-1 can easily be termed as deficiency in service and hence by filing this complaint the Complainant has prayed for certain reliefs. On the other hand the case of the OP-1 is that at the time of lodgment of the insurance claim entire treatment related papers were not filed by the Complainant and for this reason by issuing letter dated 2012.2014 the OP-2 had sought for certain documents. On 22.01.2015 the Complainant provided the required documents and on 24.03.2015 the OP-2 by issuing letter to the OP-1 has repudiated the claim of the Complainant on the ground that the insured was suffering from acute pancreatitis and has history of hypertension, diabetes mellitus for last 10 years, not only that the treatment related papers show that the patient had alcoholic consumption, which lies under the permanent exclusion clause. According to the OP-1 the Complainant is not entitled to get any relief as prayed and hence prayer is made for dismissal of the complaint.
Upon considering the facts and circumstances we are of the opinion that as in view of the exclusion clause of the policy the Complainant is not entitled to get any amount towards the medi-claim policy because treatment related papers reveal that the insured had alcoholic consumption, which exists under the permanent exclusion clause of the policy, hence repudiation of the claim by the OP-1 cannot be termed as deficiency in service as well as unfair trade practice. The Ld. Counsel for the Complainant has argued that the OP-1 has miserably failed to decide his insurance claim within six months from the date of filing of the claim form and the OP-1 is under obligation to decide any claim within the said statutory period and for this reason such dilly-dallying practice of the OP-1 can be termed as deficient. The ld. Counsel for the Complainant has placed his reliance on some rulings i.e. (2015) 4 CPR (NC) 488 & (2015) 3 CPR (NC) 366. We have gone through those rulings and it is seen by us that the Hon’ble NCDRC was pleased to hold that the insurance claim must be settled with utmost expedition and the claim should be settled within three months from the date of lodgment of the claim. In our view the rulings are applicable in the case in hand as the Insurance Company did not bother to settle the claim of the Complainant expeditiously preferably within a period of three months from the date of lodgment of the claim. Therefore such inaction on behalf of the OP-1 suffers from deficiency in service. But in view of the Section 14 of the Consumer Protection Act, 1986 speaks that if any deficiency in service is proved, then the Forum may direct the OP/s to pay compensation to the consumer for any loss or injury suffered by the consumer due to negligence of the OP/s. But in the instant complaint as the Complainant is not entitled to get any amount towards reimbursement of the treatment cost incurred by him due to permanent exclusion clause, hence question of suffering of any loss or injury caused due to negligence of the OP-1 does not arise. So the rulings as relied on by the Complainant cannot be implemented. As the complaint is devoid of any merit, hence it is liable to be dismissed.
Going by the foregoing discussion hence, it is
O r d e r e d
that the complaint is dismissed on contest without any cost against the OP-1 and dismissed ex parte without any cost against the OP-2.
Let plain copies of this order be supplied to the parties free of cost as per provisions of law.
(Asoke Kumar Mandal)
Dictated and corrected by me. President
DCDRF, Burdwan
(Silpi Majumder)
Member
DCDRF, Burdwan
(Pankaj Kumar Sinha) (Silpi Majumder)
Member Member
DCDRF, Burdwan DCDRF, Burdwan
