Today is fixed for final order of this case.
Complainant’s case in a nut-shell is that she and her husband namely Smarajit Bakshi Gupta jointly purchased Health Insurance Policy 153900/48/12/8500000642 from O.P. National Insurance Company Ltd. Prior to that they also purchased Health Insurance Policy from the O.P. The complainant got herself admitted at Apollo Gleneagles Hospital at Kolkata on 12/07/2012 due to her ailments and she was discharged therefrom on 14/07/2012 and that she had to expend a sum of Rs.42,194.70/- for her treatment in the said hospital.The husband of the complainant submitted her claim before the O.P. with all relevant documents but the O.P. has repudiated her claim relying on Clause-4.1 of the said medical Insurance Hence this case.
The complainant has prayed for a sum of Rs.42,194 alongwith Rs.10,000/- towards Litigation cost and Rs.10,000/- towards her mental pain and agony.
The O.P. Has contested this case by filing Written Version denying and disputing the the claims and contentions of the complainant with prayer for dismissal of this case with cost. The specific stand of the O.P. is that the the claim is not payable under Clause 4.1 which read as –“ All disease/injuries which are pre-existing when the cover incepts for the first time is excluded but this disease will be covered after 4 continuous claims from policy year”
POINTS FOR CONSIDERATION
- Is the case maintainable in law and fact as alleged?
- Is the case barred by limitation?
- Is the complainant a consumer as per provision of Consumer Protection Act.1986?
- Is O.P. guilty for deficiency in service as alleged?
- Is the complainant entitled to get the reliefs as prayed for?
DECISION WITH REASONS
All points are taken up together for consideration and decision.
Seen and perused the pleadings of the parties, which are supported by affidavits and the documents filed by the parties. Also perused the Written Arguments filed by the parties.
Now after due consideration of arguments advanced by the Ld. Lawyers of both sides, Written Arguments, pleadings of both parties and the documents filed by the parties we find that admittedly the complainant purchased the health Insurance Policy in question from the O.P.in the year 2012 which was valid on and from 07/06/2012 to 06/06/2013. We further find that the complainant submitted her claim before the O.P. after her discharge from Apollo Gleneagles Hospital at Kolkata on 14/07/2012 and that O.P. has repudiated such claim of the complainant after 14/07/2012 relying on clause 4.1 of the said Medical Insurance Policy and that the complainant has filed this case on 22/08/2013. Therefore we have no hesitation to hold that the case is well maintainable and this case is not barred by limitation and that the complainant is a consumer of the O.P.
Now we find that the complainant had purchased medical Insurance Policy from the O.P. Prior to her purchase of the Medical Insurance Policy in question and even after that. The complainant was admitted in Apollo Gleneagles Hospital at Kolkata on 12/07/2012 due to some ailment namely hypertension and hypothyroidism as it appears from her discharge summary. The Ld. Lawyer for the O.P. argued that the complainant was suffering from hypertension since long, so that disease of the complainant was pre-existing and for that reason as per provision of clause 4.1 of the policy the complainant is not entitled to the claim and as such the claim of the complainant was rightly repudiated by the O.P. Therefore the O.P. Is not guilty for deficiency in service as alleged. Ld. Lawyer for the complainant in reply argued that no medical test was done by the O.P. at the time of accepting the proposal of the complainant and before issuance of the Health Insurance Policy in question in favour of the complainant and no authentic documents has been filed by the O.P. to substantiate its claim that the complainant was suffering from any pre-existing disease i.e hypertension prior to issuance of the policy in question by the O.P. and the O.P. has issued the policy in question after being satisfied of the health of the complainant. We find that there is much substance in the above argument advanced by the Ld. Lawyer for the complainant as the O.P. couldn’t substantiate its claim/contention to the effect that the ailment of the complainant (hypertension) was pre-existing i.e. the complainant was suffering from hypertension long before her purchase of the medical Insurance Policy in question. Therefore we find sufficient reason to hold that the repudiation of legitimate and rightful claim of the complainant by the O.P. Insurance Company must come within the purview of “Deficiency in Service”. So we find sufficient reason to hold that the O.P. National Insurance Company Ltd. Is guilty for deficiency in service as alleged and as such the complainant is entitled to the reliefs specified below.
All points are disposed off.
Hence, it is
O R D E R E D
that the case/application is allowed on contest with cost of Rs.2000/-(Two Thousand). The complainant do get an award of Rs.42,194/-(Forty Two Thousand One Hundred and Ninety-Four) against the O.P. National Insurance Company Ltd. The complainant do get further award of Rs.3000/-(Three thousand) against the O.P. in the head of mental pain and agony. She suffered for repudiation of her legitimate claim. The O.P. National Insurance Company Ltd. is hereby directed to pay to the complainant (Rs.2000+Rs.42,194+Rs.3000) Rs.47,194/- in total within 30 days from the date here of failing which it will carry interest @ 8% per annum till realisation and the complainant shall be at liberty to realize the same by putting this order into execution in accordance with law.
Let copy of this final order be supplied to the parties free of cost forthwith in terms of Sec.5(10) of West Bengal Consumer Protection Rules 1987.
