Date of filing:15.09.2016 Date of disposal:06.04.2018
Complainant: Mr. Sanjoy Dey, S/o. Sri Sukhendu Bikash Dey, resident of Memari, Nabapally,
P.O.-Memari, P.S.-Memari, Dist.-Burdwan, Pin-713146.
-VERSUS-
Opposite Party: 1. National Insurance Company Ltd., having its Branch Office at Memari, P.O
& P.S.-Memari, Dist.-Burdwan, Pin-713146, represented by its Branch
Manager.
2. The Regional Manager, National Insurance Company Ltd., having its
Registered office at 3, Middleton Street, Post Box-9229, Kolkata-700 071.
3. Medi Assist India TPA Pvt. Ltd., having its office at 4, Premium Court, 4th
floor, Chandni Chowk Street, Kolkata-700 072, represented by its
Managing Director.
Present: Hon’ble President: Smt.Jayanti Maitra(Ray).
Hon’ble Member: Miss Nivedita Ghosh.
Hon’ble Member : Dr. Tapan Kr. Tripathy.
Appeared for the Complainant: Ld. Advocate, Subrata Ghosh.
Appeared for the Opposite Parties No.1 & 2: Ld. Advocate, Shyamal Kumar Ganguli.
Appeared for the Opposite Parties No.3 : None.
JUDGEMENT
This is a case U/s. 12 of the C.P. Act for an award directing the O.Ps. to pay Rs.1,00,000/- towards the sum insured amount against the policy, to pay Rs.1,00,000/- as compensation for mental pain and agony and to pay Rs.25,000/- as litigation cost to the complainant.
The complainants’ case in short is that he was insured under a Mediclaim Policy bearing No.154101/48/08/8500000442 issued by the National Insurance Company Ltd., through the O.P. No.1 for the period commencing from 5.8.2008 to 4.8.2009. The complainant has paid Rs.1,547/- to the O.Ps. towards the total premium against the said policy. The maximum limit of the sum insured amount of the policy for the insured was Rs.1,00,000/-. Be it mentioned here that before the inception of the policy the complainant was medically checked up by the medical team of the O.ps. The said policy was renewed time to time. Thereafter, the complainant was married and said policy was again renewed and his wife Mrs. Sudeshna Basu Dey were insured under the said Mediclaim policy being policy No.154101/48/13/8500000528 for the period from 5.8.2013 to mid-night 4.8.2014. The sum insured amount of the each insured was Rs.1,00,000/-. Lastly the complainant and his wife renewed the policy on 5.8.2015 bearing policy No.154101/48/15/ 8500000575/-.
In the mean time the wife of the complainant became seriously ill and she was suffering from abdominal pain. Then the complainant went to the Chamber of Dr.B.N. Sarkar at Burdwan on 4.7.2014 for proper treatment of his wife. The doctor treated the wife of the complainant and advised for some clinical and pathological test. After examination of those reports the doctor diagnosed that wife of the complainant was suffering from Chocolate Cyst and advised for operation. Thereafter the complainant went to the AMRI Hospital, Kolkata for better treatment and the doctor of the said hospital also advised for operation. On 19.11.2014 the patient(wife of the complainant) was admitted at RSV Hospital Pvt. at Kolkata under Dr. N.N. Ghosh. It is to be mentioned here that before admission of his wife at RSV Hospital, Kolkata the complainant intimated the fact to the O.P. No.1 vide letter dated 18.11.2014 and O.P. No.1 received the same on 19.11.2014. Dr. Ghosh conducted the operation of Endometro Cyst of his wife and ultimately the patient was discharged from the hospital on 22.11.2014. The complainant incurred all the medical expenses for the treatment of his wife from his own pocket.
After returning home from the hospital and after completion of entire treatment of the wife, the complainant lodged medical claim before the O.Ps. after observing all the necessary formalities before the O.Ps. on 23.3.2015 and submitted all the medical prescriptions, reports and bills along with all medical documents. But very surprisingly the O.P. No.1 repudiated the claim of the complainant vide letter dated 21.5.2015 stating that the claim of the complainant has been repudiated by the O.P. No.3 on the ground that the company shall not be liable to make any payment under the policy in respect of following diseases/treatment for specific waiting period surgery of Genitourinary system excluding malignancy subject to two years waiting period.
The complainant went to the office of the O.P. No.1. several times and requested the O.P. to look into the matter earnestly and to settle the claim as early as possible. But till date the O.Ps. did not take any further appropriate steps to settle the claim of the complainant which clearly indicates deficiency in service and unfair trade practice. Complainant alleges that for such deficiency in service and unfair trade practice on the part of the O.ps. the complainant has been suffering great mental pain, agony and harassment. Finding no other alternatives the complainant filed
this case before this Forum for relief as stated above.
The O.P. No.1 & 2 jointly contested the case by filing written version and stating that the complainant is the customer of these O.P. Insurance Company since 2008 and every year he renewed the policy. Thereafter the complainant was married and said policy was renewed and the complainant and his wife Sudeshna Basu Dey were insured under the said Mediclaim policy being No.154101/48/13/8500000528 for the period from 5.8.2013 to 4.8.2014 and insured amount was Rs.1,00,000/- each. Thereafter said policy was renewed in the year 2014 and 2015.
On 19.11.2014 the wife of the complainant was admitted at RSV Hospital Pvt. Ltd. at Kolkata for operation of Endometro Cyst under Dr. N.N.Ghosh at about 9 A.M. The wife of the complainant was discharged from the said hospital on 22.11.2014 after operation. The complainant incurred all expenses from his pocket. Thereafter the complainant lodged the claim before the O.Ps. on 23.3.2015 and submitted all the medical prescription, report and bills along with the claim form duly filled by the complainant. The O.P. received the claim form on 23.3.2015.
That TPA vide their letter dated 14.4.2015 informed the O.P. No.1 that after scrutiny of claim document they have observed the claim is not admissible in view of the fact that ‘patient Mrs. Sudeshna Basu Dey (27 Y/ F) was admitted in RSV Hospital Pvt. Ltd. on 19.11.2014with Chocolate Cysts : Laparoscopy puncture in left side of Chocolate Cyst of Ovary done : Policy inception date is 5.8.2013 i.e. 2nd year running policy : hence the claim is denied as per policy exclusion clause No.4.3 : hence we regret out our inability under policy terms and condition’.
That the denial clause with description are furnished below:
“Clause No.4.3 IIQ-The company shall not be liable to make any payment under the policy in respect of any expenses incurred in connection with or in respect of following decease/ treatment for specific waiting period : surgery of Genito-Urinary system excluding malignancy subject to 2 years waiting period”.
That subsequently O.P. No.3 vide letter dated 14.5.2015 informed O.P. No.1 towards denial of the claim as per policy exclusion clause No.4.3 and requested O.P. No.1 to issue letter of repudiation. Accordingly, letter of repudiation issued by O.P. No.1 on 21.5.2015 to the complainant stating the reasons for repudiation of the claim. Therefore, these O.ps. prayed to dismiss the instant complaint.
DECISION WITH REASONS
To prove this case the complainant has filed his evidence on affidavit stating the facts which he stated in his petition of complaint. O.P. No.1 & 2 prayed for adoption of their written version supported by affidavit to consider the same as their evidence. The case against the O.P. No.3 is heard exparte. From the evidence on record and from the documents filed by the parties we find that admitted position is that complainant purchased the Mediclaim Policy first in his name on 5.8.2008. Thereafter continued the policy by paying yearly premium and during continuation of said policy and after his marriage his wife Sudeshna Basu Dey was also insured under a Mediclaim Policy but the same is necessarily a new contract. The sum assured was Rs.1, 00,000/- each for the complainant and his wife and the policy number is also changed when the wife is included. The said policy in the new form started from 5.8.2013. The said policy with the wife renewed on 5.8.2015. It is also admitted fact that during substance of the policy on 19.11.2014, the wife of the complainant was admitted in the RSV Hospital Pvt. at Kolkata under Dr. N.N. Ghosh for operation of Chocolate Cyst : Laparoscopy puncture in left side was done. However, the information was only communicated to the O.P. Insurance Company for such treatment in the said hospital only on 18.11.2014.
It is the case of the complainant that the claim of the complainant for his expenses for such surgery in the hospital was repudiated by the O.P. Insurance Company vide letter dated 21.5.2015 (Annexure-K). The ground of said repudiation was under Clause 4.3(iiq) of the policy. The Mediclaim Policy papers and terms and conditions of this policy goes to show that ‘Surgery of Genito-urinary system excluding malignancy, Pilonidal Sinus, Gout & Rheumatism, Hypertension, Diabetes, Calculus diseases, Surgery for prolapsed intervertebral disc unless arising from accident, surgery of varicose veins are not payable for first two years of operation of the policy’. Admittedly, the policy in question is a contract between the parties. Therefore, the complainant cannot take the plea that he was not informed about the terms and conditions of the policy. It will be presumed that at the time of purchasing the policy he must have gone through the terms and conditions of the policy before putting his signature on the policy papers. More over the information of admission of his wife in the hospital is only intimated to the O.P. Insurance Company on just previous day of her admission in the hospital i.e. on 18.11.2014. As it is stated in the petition of complaint and it is also clear from the medical documents submitted that the patient after operation was discharged from hospital on 22.11.2014. The complainant submitted his claim form on 23.3.2015. As the O.P. Insurance Company who was informed about the treatment of his wife only on 18.11.2014, O.P. has little opportunity to inform the complainant that as per Clause No.4.3 of the terms and the conditions of the policy the wife of the complainant undergone the said surgery within two years of continuation of the policy, therefore, the complainant is not entitled to get any claim under the policy.
Therefore, the Insurance Company rightly repudiated the claim of the complainant as per Clause No.4.3 under the Mediclaim Insurance Policy. In such circumstances, the complainant is not entitled to get any relief as prayed for. We do not find any deficiency or negligence on the part of the Insurance Company and no unfair trade practice in this regard. Thus, complaint case fails. C.F. paid is correct.
Hence, it is
Ordered
that the case be and the same is dismissed on contest against the O.P. No.1 & 2 and exparte against the O.P. No.3.
Let the copies of this order be supplied to the parties free of cost.
Jayanti Maitra (Ray)
Dictated and corrected by me. President
D.C.D.R.F., Burdwan
Jayanti Maitra (Ray)
President
D.C.D.R.F., Burdwan
(Nivedita Ghosh) (Dr. Tapan Kr. Tripathy)
Member Member
D.C.D.R.F., Burdwan D.C.D.R.F., Burdwan
