Complainant by filing this complaint has submitted that he is a holder of the Mediclaim Policy being No.100600/48/07/8500006325 for the period from 02.02.2008 to 06.02.2008 on payment of premium of Rs.8,454/- for Mediclaim Policy for two years for himself and his wife and total sum assured of the said policy of Rs. 1 lac only each for cumulative bouns for the policy holders.

          It is further alleged that initially one group medi-claim policy along with his wife was purchased by the complainant when he was an employee of Central Bank of India being member of the bank employees co-operative bank ltd. with a membership No.F3/185/1818 vide Employee SPF No. 23350, group medi-claim policy No.100600/46/04/8500486 for the period from 01.03.2005 to 28.02.2006.

          On his retirement from his job, complainant on 01.02.2006 obtained one medi-claim policy from the op no.1 on payment of premium being policy No.100600/46/04/8500486 for the period from 07.02.2006 to 06.02.2007, sum assured was for Rs. 1 lac each of policy holder.

          Complainant renewed the said policy for the subsequent year and thereby the same is continuing till the date of filing of this case.

          During that policy period the wife of complainant became ill and she had been treated before the AMRI Hospital, Kolkata where she had been complained for something coming out of lower abdominal incision for one year and pain left upper abdomen for two months and doctors of the said hospital finally diagnosis the patient as Splenic SOL with incisional hernia in a known case of C.A. Overy and the wife of the complainant was admitted in the AMRI Hospital on 20.02.2008 and discharged on 28.02.2008.

          On her discharge complainant lodged one claim before the insurance company’s TPA i.e. the op no.2 for reimbursement of medical treatment expenditure for an amount of Rs.2,75,000/-.  But the op no.2 through their letter dated 10.04.2008 repudiated the claim under their exclusion clause no. 4.1.

          After being aggrieved and dissatifised with the repudiation letter of the op complainant immediately sent one letter dated 27.05.2008 to the op no.1 with a request to reconsider the claim and in the letter the complainant further submitted that as a member of the bank employees’ Co-operative Bank Ltd., and under group medi-claim insurance policy holder the complainant obtained several claims from the insurance company in the year 2005 for the treatment of his wife for Overy Cancer, operation for TAH on 30.04.2005 with 6 chemotherapy where the complainant received claim amount of Rs.39,000/- from the op/insurance company.  When the complainant further submitted that at the time of submission of proposal from the complainant had clearly stated the earlier claim and the disease which his wife suffered and did not hide anything in this respect.

          But inspite of receiving the said letter the insurance company till date did not consider the prayer for reconsideration of the claim and kept silent in the matter and for which complainant approached before this Forum for relief for negligent and deficient manner of service and prayed for settling the claim by paying Rs.1 lac with interest.

          On the contrary the Insurance Co. by filing written version has submitted that previously one complaint was filed by the complainant before this Consumer Forum vide Case No. 125 of 2010 and same was dismissed as it was not admitted.

          It is further submitted that complainant was covered under a Group Insurance Policy during 01.03.2005 to 28.02.2006 under separately negotiated terms and conditions with the Insured named Bank Employees Co-operative Bank Ltd. under a special MOU and the present complainant was insured in the group for being a member of the Co-operative Bank Ltd.  There was no individual negotiation or offer made to the complainant.

          But subsequently the complainant insured came out of the privileged group policy, may be, on his retirement from service and took a standard individual mediclaim policy for himself and his wife and this policy was issued to all general public on solicitation through the filled in proposal forms.

          Further it is submitted that the insured patient Smt Deomuni Singh had history of surgery done (Hysterectomy) in April 2005 for CA Ovary (History of past illness) in the treatment summary dated 29.02.2008 and claim had been settled under the earlier Group Policy under special terms and conditions negotiated for the insured group.  She went through further surgery on 22.02.2008 for the same illness CA Ovary, as it is evident from final diagnosis in the Treatment Summary dated 29.02.2008 and the disease CA Ovary was not a fresh onset in Feb. 2008.  It was long pre-existing before the year 2005 as evidence in the Treatment Summary dated 29.02.2008.

          Practically for the treatment cost in the hospital period from 20.02.2008  to 28.02.2008 was not considered for the disease, CA Ovary was pre-existing while taking the individual mediclaim policy with effect from 07.02.2006 under Exclusion No. 4.1 of the issued policy.

          It is further submitted that the initial claim was paid in April 2005 for the same patient is under the Group Policy taken by Bank Employees ’Co-operative Bank Ltd. under a specially negotiated MOU where pre-existing diseases were covered for the group.

          It was a tailor made policy for a large group of people who used to be the members of the Co-operative Bank and the same extended privilege is not allowed to an individual policy holder.  However, the complainant desires to get the privilege of the Group Policy being the holder of an individual family policy.  We are duty bound to comply with the terms and conditions of the individual family mediclaim policy issued to the complainant.  Despite the complainant suffering from CA Ovary which cannot be cured in an advanced stage of cancer but can be managed has misrepresented the material facts in the 12.1 of questionnaire in the proposal from declaring she being in a state of good health.  Lastly it is submitted that op has made claim on the basis of the individual Medi-claim Policy which contains Exclusion Clause No.4.1 that excludes pre-existing diseases before taking the individual Mediclaim Policy and both the insured and the insurer are duty bound to comply with the terms of the contract and any disease that is declared or not, if found pre-existing shall be beyond the scope of the policy as per exclusion No.4.1 and in the above circumstances, op repudiated the claim legal and as per term for which the complaint is not entitled to any relief.

                                      Decision with reasons

          On in depth study of the complaint including the written version and also relying upon the document filed by the op and complainant it is found that complainant as a member and employee of the Bank Employees’ Co-operative Bank Ltd. purchased proposal from as member/employee of the Bank Employees’ Co-operative Ltd. for the year 2005 to 2006 as employee of the Central Bank of India being Member No.F3/185/1818 and insured was Rs.1 lac each and at that time complainant was aged about 69 years + and his wife aged about 55 +.

          It is admitted by the op that for Group Mediclaim Insurance Policy was issued in the name of the present complainant and his wife for the year 2005 and 2006 as per MOU with the Co-operative Society of the Central Bank of India and no doubt complainant’s wife got such benefit even in case of pre-existing diseases.

          In the op’s version is that no doubt complainant’s wife was admitted to hospital and surgery for the period from 20.02.2008 to 28.02.2008.  But op has asserted as because complainant already retired from the service of the Bank, he entered into a fresh agreement for individual Medi-claim Policy and that was granted.  So, complainant is bound to prove that at the time of final proposal form discloses about his pre-existing diseases.  But in this regard we have gone through the insurance policy valid for the period from 07.02.2008 to 06.02.2009 having policy No.100600/48/07/8500006375 that on the declaration dated 07.02.2006 was accepted and Insurance Policy was issued and further considering another proposal form Group Insurance Policy it is found that complainant even after retirement he is a member of said Co-operative Bank and that MOU in between the op and Co-operative Bank of Central Bank of India has not been terminated.  Then invariably as member of the Co-operative Bank even after retirement from Central Bank of India, complainant is entitled to get benefit of the Group Insurance Policy as per MOU in between the Co-operative Society of the Central Bank of India and the present op and it is settled principle of law if any employee of a Bank retires his membership with the Co-operative Society is not terminated automatically and probably the TPA did not consult all those documents and only considering the Mediclaim Insurance Policy (Individual) repudiated the claim.

          But after considering the entire document and materials it is found that there was no question of suppressing any fact of pre-existing diseases, rather in earlier action complainant got benefit of pre-existing diseases in view of the fact as member of the Co-operative Society of the Central Bank of India he got such benefit of the Group Insurance Policy and that is till in existence and no doubt the complainant is a member of the said Co-operative Society.  So, anyway he is entitled to get all benefits of pre-existing diseases when it was in the declaration of the year 2006 that was accepted by the op which is evident from the present policy of the year 2008-09, no fresh proposal form was submitted by the complainant, but his previous declaration as member of the Co-operative Society of Central Bank of India was accepted by the op.  Then how op claimed during it as a separate and individual policy.  Another factor is that complainant supplied all documents.  So, in the above circumstances, we are convinced to hold that complainant is entitled to benefit of the Group Insurance Policy and he is also entitled to Rs.1 lac for treatment cost of his wife as per Medi-claim Policy of the year 2008-09 and no doubt TPA Heritage Health Services Pvt. Ltd. did not consider the vital note as noted in the policy for the period 07.02.2008 to 06.02.2009 to the effect proposal form declaration form dated 07.02.2006 was accepted and in fact it is Group Insurance Policy and for which complainant is entitled to Rs.1lac against said Mediclaim Policy bearing Policy No. 100600/48/07/8500006375 issued on 07.02.2006.

          In the above situation we are of the view that complainant is entitled to said claim amounting to Rs.1 lac from the op and fact remains the complainant failed to produce the vital documents of his membership before the TPA Heritage Health Services Pvt. Ltd along with claim application for which it was rejected.  But all the papers regarding his continuation of his membership was submitted from the period of 2008.  But after that continuation of his membership is not submitted.  But we consult with the membership of Co-operative Society up to 2008 because claim for the year 2008 and fact remains that it was no doubt filed by the TPA for not asking the complainant to submit his membership of Co-operative Society for the year 2008.

          In the light of the above observation we are confirmed that repudiation of the claim of the complainant by the TPA was not justified or legal.  But at the same time it is proved that complainant did not file his membership of Co-operative Society of the Central Bank of India even after retirement for which it was rejected.

          But in this regard we are of view that in future complainant shall not get any such Group Insurance Policy benefit if he does not show that he is a member of the said Co-operative Society of Central Bank of India because renewal of membership No. F3/185/1818 vide Employee SPF No.23350 is not continued after 2008 and after retirement his membership number would be changed as retired employee not as employee.

          Practically we have applied our all judicial consent in this regard of allowing this claim to the complainant along with compensation of Rs.25,000/- over the said amount on the ground in the meantime same organization have passed and in view of the above circumstances, op no.1 is liable to pay that amount by settling the entire claim of the complainant which is consumer dispute of this complaint.

          In the result, the complaint succeeds.

          Hence, it is

                                                      ORDERED

          That the complaint be and the same is allowed on contest with cost of Rs.10,000/- against the op no.1 and same is dismissed against op no.2 without any cost.

          Op no.1 is directed to pay a sum of Rs.1,00,000/- as claim the Mediclaim Policy against the claim as submitted by the complainant before the op no.1 and disposed of the matter as settled finally and further to pay a sum of Rs.25,000/- as compensation for not releasing the same after applying judicial mind and consent by the op no.1 and so op no.1 to issue a cheque of Rs.1,25,000/- along with cost of Rs.10,000/- as awarded that is total sum of Rs.1,35,000/- within one month from the date of this order in favour of the complainant and in default for each day’s delay and disobeyance of Forum’s order a sum of Rs.300/- shall be assessed as penal damages till full penal amount to the complainant.  If the said amount is collected it shall be deposited to State Cosumer Welfare Fund to this Forum.

          If op even after that disobeyance the Forum’s order in that case penal action shall be started against them and in that case further penalty of Rs.10,000/- may be imposed against the op for non-compliance of the Forum’s order.