Present : Sri A.K. Das, President
Sri L.K. Banerjee, Member
Order no. 8 dt. 7.9.2007
The case being no.223/206 was filed by Smt. Tripti Sarkar, W/o Sri Sukumar Sarkar, 16/3/3 Basudebpur Road, Sarkar Medical Hall, P.O. Shyamnagar, Dist. North 24 Parganas the petitioner to the petition of complaint against the o.ps. viz (1) National Insurance Co. Ltd., Division-III, 1, Shakespeare Sarani, Kol-71, (2) The Senior Divisional Manager, National Insurance Co. Ltd., Division-III, 1, Shakespeare Sarani, Kol-71, and (2) The Golden Trust Financial Services, 16, R.N. Mukherjee Road, Kol-1 before the forum praying for various reliefs as specified at pages 10-11 of the main petition.
The case was filed against the o.ps. u/s 12 of the C.P. Act, 1986.
The facts of he case are in briefs as follows ;
That the complainant along with her family members is a Group Medical Policy holder with the o.ps. The first policy was for a period of 1.9.03 to 31.8.04 (midnight) and it was subsequently renewed for a further period of 1.9.04 to 31.8.05 (midnight), annex-A-1. Renewed policy No. was 100300/46/04/8500025 and the policy amount was Rs.20000/-, annex-A 1. That the National Insurance Co. Ltd. the o.p. no.1 and the Golden Trust Financial Services the proforma o.p. no.3 had a MOU and by that the o.p. no.1 agreed to allow other proforma o.p. no.3 to extend Group Mediclaim Insurance coverage to the members including their family members of the Golden Multi-services Club of Golden Trust Financial Services under Group Insurance Scheme.
That under the said MOU the proforma o.p. no.3 was obliged to collect premium from the proper and remit the same to the o.p. no.1
It appears from the record that the complainant was suffering from viral hepatitis and at the advice of her physician took admission in Dreamland Nursing Home on 11.8.04 and discharged on 18.8.04, annex-A 2.
That she was under treatment between the period from 22.7.04 to 30.10.04 and underwent various tests as per the advice of her physician and for that treatment she had to incur an expenditure of Rs.22.985/-, annex-A-2.
That the complainant intimated her case of hospitalization to the GTFS who in tune advised her to submit a claim form along with relevant medical papers/documents, annex-A 3. That the complainant complied with the instruction of the GTFS on 27.11.04 for onward transmission of her claim form to the o.p. no.1, annex-A 4. The GTFSA the o.p. no.3 on their part forwarded the claim form of the petitioner to the o,.p. no.1 on 4.12.04 and as it appears from the record that the claim of the petitioner was registered by the o.p. no.1 being no.100300/46/04/85/07618.
That on 5.8.05 the o.p. no.1 intimated the complainant that her claim was repudiated on the ground that she did not comply with the condition no.5.4 i.e. she has failed to file her claim within 30 days from the date of her discharge from said nursing home, annex A 5.
That on 12.8.05 the complainant replied the o.p. no.1 through a letter explaining the cause of her delay for submitting her claim form in time and requested the o.p. no.1 to settle the matter after condonation, annex-A 6.
That without getting any satisfactory reply from the o.ps. the complainant again wrote a letter to the o.p. no.2 on 19.8.05 for settlement of her claim. That the o.ps. did not take any action on the request made by the petitioner.
Finding no alternative the petitioner approached the forum for relief. Hence this case is for adjudication.
That o.p. no.1 submitted a w/v by way of affidavit wherein it stated that he claimant has declared in her claim petition para no.6 that she intimated on 14.8.04 and she submitted her claim form on 11.12.04. that it is a clear violation of policy condition as per 5.4 of the terms and condition which states the claim is to be filed within 30 days from the date of discharge from hospital. The o.p. no.1 prayed for dismissal of the case on the ground as stated in the w/v.
The o.p. no. 3 in its affidavit stated that they acted as agent of the o.p. no.1 and o.p. no.1 is the sole absolute authority to take any decision of its own as regards settlement of claim which it may think fit and proper. The o.p. no.1 before taking decision as regards such settlement of claim did never consult with proforma o.p. no.3 and they are not even obliged to do so. It has performed its duty as per the provision of he terms and conditions of the policy and the complainant is not entitled to any relief as against the proforma o.p. no.3.
It appears from the record that the o.ps. have been contesting the case all along by way of filing w/v supported by affidavit denying very emphatically all the material allegations to the petition of complaint.
Now the question comes uppermost in the mind whether the petitioner is entitled to have any relief in this case within the ambit of C.P. Act, 1986.
The o.p. no.1 has cited the pre/existing disease and non submission of the claim as the main reasons for repudiation of the claim of the complainant.
It is evident from the record that the petitioner got treatment during the period of her policy. It is admitted that he is a policy holder.
Fact that the petitioner could not submit her claim within 30 days from the date of her release from the nursing home. She submitted her claim on 27.11.04 and it was acknowledged by the o.p. no.1 on 4.12.04 and repudiated on 12.8.05. The o.p. no.1 took more than 8 mouths to take decision to repudiate the claim of the petitioner.
Mere technicality for non submission of claim in time cannot be the sole grand for repudiation. Moreover, there is no evidence on record of suggest that the petitioner is a patient of pre existing disease.
If we take into account the grounds for repudiation of the claim of the petitioner by the o.p. then it would help the o.p. to wash off their hands in every case. The Hon’ble National Commission, New Delhi holds the view in respect of the pre existing disease that “The insurance company could never be held liable to pay any claim because every person suffers for symptom of same or other disease without knowing of it. This makes an insurance policy nothing but a contract to accept a premium without any bona fide intention of giving any compensation to the insured”. The o.ps. have no solid ground to stand by their leg to defend the case. It is evident that the o.ps. have-not applied their mind while dealing with the case.
The forum have perused all the documents available with the record, considered submissions made by the parties concerned and also all such aspects so l0ng discussed in detail and have no hesitation in coming to conclusion that the complainant has been able to prove his case to the to the hilt, so as to get adequate relief in this case. The o.ps. action smacks of dereliction of duty and deficiency in service in rendering the positive service to the petitioner’s claim which she entitled to have as per the terms and conditions of the policy. The reasons as cited by the o.ps. for not entertaining the claim of the petitioner specially for pre existing disease is not convincing and not entertained by the forum.
The case succeeds on contest.
Hence,
Ordered,
The o.p. nos.1 and 2 are directed to reimburse within 45 days from the date hereof a sum of Rs.20,000/- (Rupees twenty thousand) only (maximum amount as insured) to the petitioner towards the expenditure as incurred by her during the period of her treatment in the nursing home and also Rs.5000/- (Rupees five thousand) only and Rs.1000/- (Rupees one thousand) only respectively as compensation and litigation cost for causing needless mental agony and harassment to the petitioner through its negligence, inaction and deficiency, failing which it will carry a simple interest @8% p.a. till realization of the full payment as ordered.
Let copy of this order be supplied to the parties free of cost.
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Member President
