Date of filing: 13.07.2016 Date of disposal: 15.03.2018
Complainant: Arabinda Mukherjee, S/o. Late Sarat Chandra Mukherjee, at present residing at Nidhi Apartment, IInd Floor, New Upper Chelidanga, near Bhakti Bhaban Lane, Asansol – 4.
Opposite Party: 1. Senior Divisional Manager, Kolkata -1 Division, National Insurance Company Limited, 3, Middleton Street, Post box No. 9229, Kolkata – 71.
2. Senior Divisional Manager, Genins India TPA Ltd., a Third Party Administrator in Health Insurance, having its office at 15, Ganesh ch. Avenue, 3rd floor, Kolkata – 13.
3. Branch Manager, National Insurance Company Limited, Asansol Branch, having its office at Durga Market, 46, G. T. Road, Asansol, Dist: Burdwan, Pin – 713 301.
Present:
Hon’ble President: Smt. Jayanti Maitra (Ray).
Hon’ble Member: Smt. Nivedita Ghosh.
Hon’ble Member: Dr. Tapan Kumar Tripathy.
Appeared for the Complainant: Ld. Advocate, Debjyoti Banerjee.
Appeared for the Opposite Party No. 1 & 3: Ld. Advocate, Shyamal Kumar Ganguli,
Appeared for the Opposite Party No. 2: None (ex parte).
J u d g e m e n t
This is a case of u/S. 12 of the C.P. Act, 1986 alleging repudiation of the insurance claim against the Ops by unfair means.
The complainant’s case in short is that he and his family including his daughter Asmita Mukherjee had been insured under the Health Insurance Scheme under Mediclaim policy since 24.10.2008. On 24.12.2006 the complainant along with her daughter and other relatives was proceeding from Asansol to Nabadwip when the car met with an accident and was injured. For treatment they were taken to Apollo Gleneagles Hospital at Kolkata. The daughter, Asmita Mukherjee, was seriously injured as the bone below her eyes was broken and for this she had been administered 167 stitches on her face. She was discharged from the Hospital on 29.12.2006 but her treatment continued. On 07.11.2013, the daughter, Asmita, was brought under the treatment of Dr. Asis Das who in his issued prescription left a note “RTA 2006 suicidal Attempt”. In the said accident Asmita had some facial deformities and it was affecting her psychological factors also. So, she was brought under the treatment of Dr. V. S. Rathod, a facial surgeon and underwent a cosmetic surgery at Columbia Asia, Salt Lake. After that the complainant lodged the claim for reimbursement of the expenses onwards treatment of Asmita with the said Insurance Company. The Insurance Company, initially, by a letter dated 01.5.2015 issued for and behalf of Genius India TPA Ltd. repudiated the claim alleging that the same is excluded as per clause 4.1 of NIC policy condition. Subsequently, by a letter dated 31.7.2014 the OP-1 instructed their Third Party Administrator, Genius India TPA Ltd. that the Exclusive Clause No. 4.1 is not attached. Ultimately, the Insurance Company repudiated the claim on 05.8.2014. They did not give any formal letter to the complainant but on his enquiry in the office of Notary, on 27.7.2015, the complainant has been informed that the claim was rejected under clause 4.1 of the policy conditions, the OP relied upon the prescription of Dr. Asis Das on 07.11.2013 till the date, however, any repudiation letter had not been received by the complainant. Also, according to the complainant, Dr. Asis Das’s observation was out of some misunderstanding. When Asmita was treated by Dr. Asis Das, she was suffering from depression due to her facial deformity. She used to say if the deformity would not been cured she would have done anything to end her life. However, she actually did not take any suicidal attempt.
The case has been contested by the OP-1&3 by filing written version denying all the material allegations made by the complainant in his petition of complaint. The case of the OP-1&3 is that the complainant submitted a claim stating the fact that on 25.12.2006 the complainant along with her daughter and other relatives was proceeding to Nabadwip at around 5.30 a.m. when the car met an accident. The occupants were seriously injured and admitted Apollo Gleneagles Hospital and released on 29.12.2016 when the final diagnosis was multiple facial laceration and abrasion with tissue loss arising out of fracture left jygomatic arch and after release the patient was again treated at Medical Super Speciality Hospital, Kolkata and was under treatment of Dr. Abir Mukherjee, Dept. of Psychiatry on 12.11.2013 and under Asis Das, Dept. of Neurology on 07.11.2013. Thereafter on 18.11.2013 Asmita, the daughter of the complainant underwent a cosmetic surgery at Columbia Asia Hospital, Salt Lake under Dr. Vikram Singh Rathod and discharged on 20.11.2013. Thereafter the complainant filed a claim petition with OP-2 for reimbursement of an amount of Rs. 1, 30,000=00 which was acknowledged on 21.4.2014. the OP-2 informed the OP-1 that “The present claim is for Liposuction of Abdomen with fat grafting of fact done in case of post Traumatic facial scar as reflected from discharge summary in a third year of policy coverage incepted since 30.11.2010. Arising out of RTA followed by facial
Scar in 2006 i.e. prior to inception of policy. Hence present claim is repudiated as per clause no. 4.1 of NIC policy condition”. Along with said observation the original claim document was returned to OP-1 for perusal and issue of repudiation letter. On 27.6.2014 the OP-1 intimated the complainant regarding repudiation of claim in terms of clause no. 4.1. On 22.9.2014, OP-2 intimated OP-1 that they have further reviewed the claim documents and as per paneled doctor’s opinion the claim is not payable due to exclusion clause. From above facts and circumstances it is amply clear that the Facial Scar that in the instant case of post traumatic facial scar was due to the accident occurred in 2006 while the policy was incepted on 24.10.2008 i.e. the incident was pre-existing in nature and as per policy condition 4.1 any complication arising from pre-existing injuries are excluding from policy coverage. In the discharge summary of Columbia Asia also mentioned follow up with Dr. Sharmistha Chakraborty (psychiatrist) as usual and according to policy condition no. 4.10 treatment cost related to psychiatric disorder and suicidal attempt are excluded from the policy coverage. The OP-1&3 have prayed that the instant complaint petition is not tenable and beyond the policy conditions and not within the jurisdiction of Ld. Forum due to which earlier petition due to self-same case was dismissed in CC/83/2016.
Decision with reasons:
The complainant filed this complaint against the Ops as the Ops have repudiated insurance mediclaim of his daughter on the ground of the Policy condition as per clause No. 4.1 of NIC policy condition.
So the moot question we have to decide in this case is whether the repudiation made by the Ops is justified or not.
The case of the complainant is that on 25/12/2006 their car met with an accident and her daughter was seriously injured and the bone below the eye was broken and doctors administered 167 stitches on her face and discharged from hospital on 20.12.2006. Thereafter continuous treatment of infirmities and illness arising out of the said accident and on 06.11.2013 the daughter of the complainant was treated by Dr. Mohanta and thereafter she was treated by Dr A. Das on 07.11.2013 and Dr. A. Mukherjee on 12.11.2013. Thereafter she was brought under the treatment of Dr. V.S. Rathod, and she underwent a cosmetic surgery at Columbia Asia, Salt Lake and for such treatment Rs. 1,30,000=00 was spent by the complainant.
From the case record we found a certificate issued by Dr. V. S. Rathod where it is written that “……………….. Perused to me with scar face following RTA in 2006. She underwent scar revision & Fat injection at Columbia Asia Hospital in 2013”.
From the said certificate it is very much clear that the treatment at Columbia Asia Hospital in 2013 is a follow up treatment of the incident in 2006, when neither the complainant nor the daughter of the complainant was under any insurance policy regarding mediclaim under the National Insurance Co. Ltd. The said Insurance Policy for mediclaim was taken on and from 30.10.2008 by the complainant and his family members. So it is very much clear from the documents and the petition of complaint that the treatment in the year 2013 for which reimbursement was claimed is a pre-existing one, as it was an aftermath of the accident took place in the year 2006.
The terms and conditions of Pr-existing diseases as follows:
4.1 Pre-existing diseases
“………………………………………. Any complication arising from pre-existing ailment/disease/injuries will be considered as a part of the pre-existing health condition or disease”.
So the repudiation of the claim by the Ops - National Insurance Co. Ltd. is very much justified and within the terms and conditions of the Policy. Therefore, the complainant has failed to prove his case. Hence, it is
O r d e r e d
that the Consumer Complaint being No. 117/2016 be and the same is dismissed on contest against the Ops without any cost.
Let plain copies of this order be supplied to the parties free of cost as per provisions of law.
Dictated & Corrected by me: (Jayanti Maitra (Ray)
President
(Tapan Kumar Tripathy) DCDRF, Burdwan
Member
DCDRF, Burdwan
(Tapan Kumar Tripathy) (Nivedita Ghosh)
Member Member
DCDRF, Burdwan DCDRF, Burdwan
