Consumer Complaint No. 21 of 2016
Date of filing: 22.02.2016 Date of disposal: 09.9.2016
Complainant: Mr. Prem Chandy, S/o. E. J. Chandy, resident of D-305, Tereskova Path, Bidhan Nagar, Durgapur, District: Bardhaman, West Bengal, PIN – 713 212.
-V E R S U S-
Opposite Party: 1. National Insurance Co. Ltd., being represented by Branch Manager, Benachity Branch, National Insurance Co. Ltd., having its office at Ajit Banerjee Building, Nachan Road, Benachity, Bardhaman, West Bengal, PIN – 713 212.
2. Benachity Branch, National Insurance Co. Ltd., being represented by Branch Manager, National Insurance Co. Ltd., having its office at Ajit Banerjee Building, Nachan Road, Benachity, Bardhaman, West Bengal, PIN – 713 212.
3. Branch Manager, Benachitt Branch, National Insurance Co. Ltd., having its office at Ajit Banerjee Building, Nachan Road, Benachity, Bardhaman, West Bengal, PIN – 713 212.
4. Senior Branch Manager, Benachity Branch, National Insurance Co. Ltd., having its office at Ajit Banerjee Building, Nachan Road, Benachity, Bardhaman, West Bengal, PIN – 713 212.
Proforma Opposite Party: 5. Mrs. Sharon Abraham, W/o. Prem Chandy, resident of D-305, Tereskova Path, Bidhan Nagar, Durgapur, District: Bardhaman, West Bengal, PIN – 713 212.
6. Mrs. Saramma Chandy, W/o. E.J. Chandy, M/o. Prem Chandy, resident of D-305, Tereskova Path, Bidhan Nagar, Durgapur, District: Bardhaman, West Bengal, PIN – 713 212.
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, Sanyuk Banerjee.
Appeared for the Opposite Party (s): Ld. Advocate, Shyamal Kr. Ganguli.
J U D G E M E N T
This complaint is filed by Complainant u/S. 12 of the Consumer Protection Act, 1986, alleging deficiency, as well as, unfair trade practice against the Insurance Company as the Insurance Company has repudiated his legitimate insurance claim arbitrarily and illegally on flimsy pretext.
The brief fact of the case of the Complainant is that for the purpose of safety and security of his family he obtained medi-claim policy on and from 01.01.2010 for protection of himself and his family members including his wife and mother. The said policy was renewed from time to time and is still continuing. On every renewal the Insurance Company used to issue the policy showing different numbers. The OP-2 is the issuing branch and the OP-3 is the Branch Manager of the OP-2, the OP-4 is the Senior Branch Manager of the issuing Branch. During validity of the medi-claim policy on 20.12.2014 the wife of the Complainant-Proforma OP-5 was admitted in the emergency department of the Mission Hospital, Durgapur due to headache and tingling sensation of the body. After treatment and upon having some pathological tests it was diagnosed as Migraine (Probable Basilar). The Hospital Authority discharged the patient on 21.12.2014. Thereafter as per direction of the concerned doctor the patient was under the treatment and supervision under him and used to visit the said hospital for consultation with the treating doctor from time to time on 03.02.2015 and 19.03.2015 respectively. On 19.03.2015 the patient was referred to the ENT for treatment of the problem of her nose. On the said date the patient visited the ENT doctor and several tests and investigations including CT Scan done. On 20.03.2015 after perusal of the CT Scan report the ENT doctor advised the patient to get admission at the Hospital on 23.03.2015. After admission the patient underwent certain other tests and investigations and thereafter the patient was operated upon on 23.03.2015 and got discharge from the Hospital on 24.03.2015. After completion of the treatment of the Proforma OP-5 the Complainant for getting reimbursement the expenditure incurred by him towards the treatment intimated the matter to the OPs and accordingly the claim form was issued. The Complainant lodged the claim claiming the expenditure along with all relevant papers and documents with the OP-2 on 25.03.2015. The wife of the Complainant was suffering from Deviated Nasal Septum of her right side nose. After lodgement of the claim the OP-4 by issuing a letter dated 02.06.2015 surprisingly repudiated the claim mentioning the disease of his wife to be a Congenital Defect which falls under Exclusion Clause no-4.8. Thereafter by issuing letter dated 04.07.2015 the Complainant requested the OP-4 to review the claim. But the OP-2 by issuing a letter had mentioned that the Complainant had withdrawn his claim through letter dated 02.06.2015 and accordingly the OP-2 closed the claim file of the Complainant as ‘NO CLAIM’. Thereafter the Complainant went to the treating doctor for cross checking as to whether the disease Deviated Nasal Septum for which the patient was operated upon can be termed as a congenital disease or not. The treating doctor opined that the disease occurred to her due to recurrent infection in the nose and Paranasal Sinuses. The doctor has also opined that the disease is not a congenital one. Since obtaining the medi-claim policy the wife of the Complainant had never suffered from any problem concerning any congenital disease having the name as Deviated Nasal Septum. The Complainant has mentioned that for argument sake if the disease was there, the existence of the same was not within the knowledge of the Complainant or his wife at the time of taking out the policy. The OPs did to bother to consider the claim of the Complainant and illegally repudiated the legitimate claim, not only that by issuing letter it was stated that the Complainant himself had withdrawn the claim and for this reason the claim file has been closed by the OP-2 as ‘No Claim’. As the grievance of the Complainant have not been redressed by the OPs before coming to this Ld. Forum and having no alternative the Complainant had approached before the Ld. Forum by filing this complaint praying for direction upon the Insurance Company for making payment of Rs.42,240=00 along with interest @9% p.a. on the said amount from the date of lodgement of the claim till realisation, Rs.40,000=00 as compensation due to harassment, mental agony, pain and suffering and litigation cost of Rs.10,000=00 to him.
The petition of complaint have been contested by the OP-1, 2, 3 and 4 by filing written version jointly contending that the Complainant was enjoying a Hospitalisation & Domiciliary Hospitalisation benefit policy for self, wife and mother since 01.01.2010 and as per policy condition it has been clearly stated that during the operative period of the policy both the insurer and insured would be guided strictly according to the terms and conditions of the policy. With complaint of headache recurrent episode of cough, nasal blockage the patient-wife of the Complainant got admission at the Mission Hospital, Durgapur on 22.03.2015 and after diagnosis it was detected that the patient was suffering from Deviated Nasal Septum to the right side with inferior spur to caudal dislocation of nasal septumticiside. During hospitalisation operation was done under general anaesthesia on 23.03.2015 and the patient got discharge on 24.03.2015 under stable condition. The patient was under the treatment of Dr. Nishant Kumar. For operation the Complainant paid a sum of Rs.36, 082=00 towards various tests including investigation charges. The Complainant lodged one claim application on 25.03.2015 for Rs.42, 240=00 under three different heads of expenses i.e. room rent, surgeon, anaesthesia charges, blood, oxygen etc. The Insurance Company communicated to the Complainant by issuing letter dated 02.06.2015 receipt of the claim application in respect of surgery of Deviated Nasal Septum and stated that Deviated Nasal Septum is a congenital disease/defect which falls under exclusion clause no-4.8 and therefore file would be closed as no claim and requested the insured to make comment in respect of repudiation, if any. But the OP did not receive any reply from the end of the Complainant within 15 days, so the claim was repudiated by the OPs. By issuing a letter dated 25.06.2015 the Complainant was intimated that deviated nasal septum is a congenital external defect which falls under exclusion clause no-4.8 of the policy and for this reason the claim was repudiated by the Insurance Company. According to the OPs such repudiation cannot be termed as deficiency in service as well as unfair trade practice on their behalf as they have acted as per the policy conditions and terms. The OPs have prayed for dismissal of the complaint.
Both parties have filed several papers and documents in support of their respective contentions.
We have carefully perused the record; documents submitted by the contenting parties and heard argument form the ld. Counsel for the parties at length. We have noticed that there are some admitted facts in the case in hand i.e. the complainant obtained one medi-claim policy from the insurance company started on and from 01.01.2010 for protection of him as well as his family members including his wife and mother, the policy was renewed from time to time and still continuing, during validity of the said policy on 20.12.2014 the wife of the complainant was admitted at the emergency department of Mission Hospital,. Durgapur due to headache and tingling sensation of the body, several pathological tests investigations made, it was diagnosed as typical migraine, namely, probable basilar, the hospital authority discharged on 21.12.2014, the complainant remained under the treatment of the treating doctor and used to visit hospital for consultation with the doctor from time to time, on 19.3.2015 the patient was referred to the ENT for his treatment of her nose, she visited ENT doctor wherein certain investigations along with CT Scan was done, on the basis of the report of the CT Scan the patient was directed to get admission at the said hospital, accordingly the wife of the complainant got admission at the Mission Hospital, Durgapur on 22.3.2015, surgical intervention was done on 23.3.2015, the patient do got discharge therefrom on 24.3.2015, after completion treatment the complainant intimated the Insurance Company for reimbursement towards the expenditure as incurred by him for the treatment of his wife under the medi-claim policy, claim form issued, claim form lodged with the company along with relevant papers and documents, it was detected the wife of the complainant was suffering from deviated nasal septum of her right side nose, the OP-4 by issuing a letter dated 02.6.2015 repudiated the claim of the complainant on the ground of the exclusion clause no. 4.8 as the disease of the wife of the complainant false, under the said clause being congenital defect, by issuing letter complainant requested the op-4 to review the claim, but to no effect, ultimately the op-2 closed the file as no claim. The allegation of the complainant is that the Insurance Company has repudiated his legitimate insurance claim illegally and whimsically based on false pretext. Hence this complaint is initiated by him praying for certain reliefs along with reimbursement of the medical expenditure under the medi-claim policy. The case of the Insurance Company is that repudiation was made properly, not illegally, as the disease from which the wife of the complainant was suffering from is a congenital defect hence, the claim cannot be permissible under the exclusion clause no. 4.8 as per the terms and the conditions of the policy. According to the Ops as there is no deficiency in service, as well as, unfair trade practice in repudiating the claim, prayer is made for dismissal of the complaint.
Therefore, now we are to adjudicate based on treatment related papers of the wife of the complainant and other documents as submitted by both parties as to whether the disease for which the wife of the complainant being an insured was operated upon and suffering from is a congenital or not. From the copy of
BOI National Swastha Bima Policy it is evident that under the exclusion clause no. 4.8 it is mentioned convalescence, general debility, run down condition or rest cure, congenital external disease or defects or anomalies, sterility, infertility, venereal disease, intentional self-injury and use of intoxication drug/alcohol, the claim is not permissible under the said policy. From the discharged summary dated 21.12.2014 issued by the Mission Hospital, Durgapur, (R/P29) it is evident that the suffering of the patient was diagnosed as typical migraine, (probable basilar) and it is mentioned in the said document that the patient presented in the emergency department with history of headache and tingling sensation of the body. There is no history of weakness and no other focal deficit. The CT Scan report dated 20.3.2015 of the Mission Hospital, Durgapur reveals nasal septum is deviated to right side, mild mucosal thickening is noted in bilateral maxillary sinus and right frontal sinus and left middle ethmoid air cells are Opaque. In the discharge certificate dated 24.3.2015 issue by the Mission Hospital, Durgapur it is mentioned that procedure was done through general aesthesis on 23.3.2015 and at the time of discharge of the condition of the patient was stable it was diagnosed as deviated nasal septum to right side with inferior spur to caudal dislocation of nasal septum. Based on the said averment as mentioned in the discharge summary the IC has repudiated the claim of the complainant by issuing letter dated 02.6.2015 (finally) due to deviated nasal septum is a congenital external defect, falls under exclusion as per clause no. 4.8 of the policy condition. It is true that the exclusion clause no. 4.8 denotes that is there is any congenital defect or disease the insured is not entitled to get any claim from the insurance company in view of the medi-claim policy. After repudiation of the said claim the complainant made several written correspondences with the IC to review his claim and at that point of time he submitted one doctor’s certificate of the Mission Hospital, Durgapur (RP24) from it is evident that the treating doctor had opined that the deviated s nasal septum is not a congenital defect but an acquired one due to recurrent infection of nose & P.M.S. The said document has not been challenged by the Ops and hence the certificate has reached it finality. As the treating doctor has opined that the defect or disease is not a congenital one, therefore, the IC cannot debarred the complainant from getting the reimbursement towards medical expenditure for the treatment of his insured wife. So it can be said that repudiation of the insurance claim was done by the Ops illegally and without perusing the entire documents. Moreover, in the discharge summary dated 24.3.2015 of the Mission Hospital shows the word ‘dislocation of nasal septum’. The word dislocation means which has been dislocated from its original location due to some reasons. In the instant case also the certificate of the treating doctor corroborates the word ‘dislocation’ of the discharge summary dated 24.3.2015. Therefore, it can be said that the nasal septum of the complainant was dislocated and due to that reason the wife of the complainant had to undergone surgical intervention. The complainant has prayed for reimbursement of the medical expenditure as incurred by him towards the treatment of wife to the tune of Rs. 42,240=00 along with interest and complainant has also prayed for compensation and litigation cost. It is true that before coming to the court of law the claim of the complainant had not been allowed and grievance not redressed by the Ops. As the complainant by filing this complaint had to incur some expenses, in our view the complainant is entitled to get some amount towards litigation cost. It is mentioned earlier that as the claim has been repudiated illegally, the said action reveals deficiency in service on behalf of the Ops and for this reason the complainant is also entitled to get compensation.
Going by the foregoing discussion hence, it is
O r d e r e d
that the complaint is allowed on contest with cost against the OP-1 to 4. That the OP-1 to 4 are directed to pay either jointly or severally a sum of Rs. 42,240=00 to the complainant towards the medical expenditure and reimbursement as incurred by him for the treatment of his insured wife within a period of 45 days from the date of passing of this judgment, in default, the said amount shall carry penal interest @8% per annum for the default period. The Op 1 to 4 are also directed to pay either jointly or severally a sum of Rs. 3,000=00 towards compensation due to prolonged harassment, mental agony and pain and litigation cost of Rs. 1,000=00 to the complainant within a period of 45 days from the date of passing of this judgment, in default, the complainant will be at liberty to put the entire decree in execution as per provisions of law. There is no order against the Proforma OP Nos. 5&6.
Let plain copies of this order be supplied to the parties free of cost as per provisions of Consumer Protection Regulations, 2005.
(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
