Consumer Complaint No. 47 of 2016
Date of filing: 22-03-2016 Date of disposal: 30-11-2016.
Present :
Sri Asoke Kr. Mandal Hon’ble President,
Sri Pankaj Kr. Sinha Hon’ble Member,
Mukuta Jash, W/o. Amiyo Jash, residing
at Vivakananda College More, Hazra Math,
P.O.-Sripally, P.S. & Dist.-Burdwan, Pin-713103. Complainant
VERSUS
- The Divisional Manager,
National Insurance Company Ltd.,
Burdwan, Bhanga Kuthi, P.S. &
District-Burdwan.
- The Senior Divisional Manager,
National Insurnce Company Ltd.,
Division-III, 8, India Expange Place,
(Ground Floor) , Kolkata-700 001.
- Manger of Medi Assisst India Pvt. Ltd.,
Chnadni Chalk Street, 4th floor,
Premier Court, Kolkata-700 072 Opposite Parties.
Appeared for the complainant : Ld. Advocate Santi Ranjan Hazra.
Appeared for the O. P. Nos. 1 & 2 : Ld. Advocate Shyamal Kumar Ganguli.
Appeared for the O. P. No.3 : None.
JUDGEMENT
This is a case U/s. 12 of C.P. Act for an award directing the O.Ps. to pay Rs.30,000/- along with interest thereon as cost of medical treatment, to pay Rs.20,000/- as compensation for mental agony and harassment, to pay Rs.15,000/- as compensation for unfair trade practice and to pay Rs.10,000/- as litigation cost to the complainant.
The complainant’s case in short is that in the month of March, 2013 the son of the complainant named Anirban Jash subscribed into a mediclaim policy of the O.P., National Insurance Company Ltd. for himself and for his parents. Number of the policy issued to the complainant was 154100481485/09/08/9600003802. Annual premium of Rs.1,556/- was duly paid. Said policy was covered upto Rs.1,00,000/- and was renewed year to year, since its inception. Last policy was valid for the period from 31.3.2015 to 30.3.2016. The O.P. No.3 is the TPA related to said policy. Since the month of July, 2014 the insured Mukuta Jash (complainant) had been suffering from excessive bleeding. So, she was medically treated by Dr. Rabindra Nath Dalui. As per advice of the doctor, her necessary investigation/pathological tests were made and consulting pathological reports, said doctor suggested the complainant to be admitted in Sisu Mongal Nursing Home to undergo surgical operation and accordingly she was admitted in Sisu Mongal Nursing Home on 25.11.2015. Said operation was successfully done and the complainant was released from nursing home on 29.11.2015. For such operation the complainant incurred total Rs.30,000/-. On 8.12.2015 the complainant placed her claim for reimbursement of such amount of Rs. 30,000/- filling up the prescribed reimbursement claim form and submitting related documents before the O.P., National Insurance Company. Thereafter, on downloading a mail, the complainant came to know that the O.P. National Insurance Company repudiated the claim of the complainant relying on exclusion clause No.4.1, which provides about pre-existing disease. The treating doctor Rabindra Nath Dalui in writing confirmed that the disease of the complainant related to the surgical operation was not pre-existing, as alleged by the O.P. Said doctor in writing acknowledged also that in the month of March-2013 the patient was completely free of disease and all investigations were within the normal limit. On 19.2.2016 the complainant through her husband communicated said fact to the office of the O.P. submitting said written acknowledgement dated 18.2.2016 and made request to reconsider the claim but the O.Ps. did not pay any heed. The O.Ps. with ill-intention repudiated the claim of the complainant. As such there were deficiency in service and unfair trade practice on the part of the O.Ps. and for the act of the O.Ps. the complainant has been suffering mental agony and harusment. So, the complainant is entitled to get the amount incurred for her treatment and to get compensation for mental agony and harassment. The complainant has been forced to come before this Forum to get relief. As such she is also entitled to get litigation cost. Hence, this case with the prayer as embodied in the body of the complaint.
The O.P. No.3 inspite of service of notice upon him did not appear to contest this case. Accordingly, the case was heard ex-parte against him.
The O.P. No.1 & 2 contested this case by filing joint written version while stating inter-alia that the case is not maintainable, the complainant has no locus standy to file this case, this Forum has no jurisdiction to try this case and the complainant is not the consumer under these O.Ps. It has been further stated by these O.Ps. that the complainant was enjoying a mediclaim policy, the inception date of said policy was 31.3.2014, said policy was renued for the period from 31.3.2015 to 30.3.2016, such policy is second year running policy, as per prescription submitted by the complainant it has been observed that on 21.3.2011 the complainant was medically treated by Dr. Rabindra Nath Dalui and from said case history it was opined by the doctor that the patient (complainant) had been suffering from the ailment of Menorrhgia and subsequently the doctor Dalui treated her for her pre-existing disease, ultimately she was operated at Sisu Mongal Nursing Home on 25.11.2015 and released on 29.11.2015 from said Nursing Home, the discharge certificate issued by said doctor shows that the complainant was suffering from Menorrhgia and Thick Endomented, according to the policy condition, the claim is not payable as the complainant had been suffering from Menorrhgia and Thick Endomented snce before the policy inception, as such the claim of the complainant was denied under the policy exclusion clause No.4.1 (pre-existing disease), the O.P. No.3 being the TPA of the policy vide their letter dated 7.3.2016 intimated the O.P. No.1 that according to the documents it appeared that the case should be denied as per policy exclusion 4.1 and requested to issue a repudiation letter to the insured and accordingly a repudiation letter was issued by O.P. No.1 on 21.3.2016. So, the case is liable to be dismissed with cost against these O.Ps.
DECISION WITH REASON
To prove her case the complainant has relied upon her evidence on affidavit and photocopies of several documents including policy certificate, identity card, letter dated 23.11.2015 issued by the Finance Officer of University of Burdwan, discharge certificate, prescriptions of several dates, bills showing cost of diagnostic test, final bill issued by the Sisu Mongal Nursing Home showing total cost amounting to Rs.30,000/- and showing payment of such amount by the complainant to the Nursing Home, several money receipts showing purchase of medicines and claim form submitted on 8.12.2015. The complainant has also submitted the photocopies of certificate issued by Dr. Rabindra Nath Dalui on 18.2.2016 and written argument submitted on 22.11.2016.
On the other hand the contesting O.P. Nos.1 & 2 has submitted some photocopies of the documents which have also been filed by the complainant in this case and the letter dated 7.3.2016 issued by the O.P. No.3 to the Divisional Manager (O.P. No.1). The Ld. Advocate for the complainant has relied upon the observation of Hon’ble National Commission made in Tarlok Chand Khanna Vs. United India Insurance Company Ltd. case made in Revision Petition No.686 of 2007.
We carefully perused the evidence adduced by the parties, contents of the pleadings and said observation of the Hon’ble National Commission.
It is not disputed that the complainant was enjoying a mediclaim policy for the period from 31.3.2015 to 30.3.2016 and the inception date of said policy was 31.3.2014. It is also not disputed that the complainant was medically treated by Dr. Rabindra Nath Dalui since July, 2014 to 29.11.2015 and within this time the complainant was to undergo one surgical operation and after successful operation the complainant was released from Sisu Mongal Nursing Home on 29.11.2015. The complainant’s case that the complainant incurred total Rs.30,000/- towards her treatment and she made claim for reimbursement on 8.12.2015 filling up the prescribed format and submitting the relevant papers, has not been denied specifically by the contesting O.P. Nos.1 & 2. The photocopies of the documents submitted by the complainant and also submitted by the O.P. No.1 & 2, support the above case brought by the complainant.
The contesting O.P. Nos.1 & 2 has taken a plea that the complainant was medically treated by Dr. Rabindra Nath Dalui on 21.3.2011 and from said history it was opined by their doctor that the patient was suffering from ailments of Menorrhgia and Thick Endomented since 21.3.2011 and subsequently the doctor treated her for said pre-existing disease, ultimately she was undergone operation on 25.11.2015 and released on 29.11.2015 from Sisu Mongal Nursing Home. To prove this specific case the contesting O.Ps. relied upon the prescription dated 21.3.2011, the discharge certificate issued by Sisu Mongal Nursing Home on 29.11.2015 and the letter dated7.3.2016 issued by Medi Assist India, TPA Pvt. (O.P. No.3). The O.P. No.3 by said letter has stated that the case should be denied as per policy exclusion clause-4.1 and requested to the O.P. No.1 to issue repudiation letter to the insured. The doctor of O.P. No. 3 who opined that the complainant had been suffering from pre-existing disease named Menorrhgia and Thick Endomented, has not submitted his view supported by affidavit. In the letter dated 7.3.2016 the O.P. No.3 has not disclosed as to why he has come to the conclusion that the complainant had been suffering from pre-existing disease named Menorrhgia and Thick Endomented and as such the claim of the complainant should be denied and the repudiation letter should be issued to the complainant. We carefully perused the prescription dated 21.3.2011 but we find nothing in said prescription that on 21.3.2011 Dr. Rabindra Nath Dalui opined that the complainant was suffering from the ailment Menorrhgia and Thick Endomented, on 21.3.2011. In the complaint the complainant has specifically stated that the complainant was suffering from excessive bleeding from the month of July, 2014 and as such she was medically treated by Dr. Dalui and she was undergone for surgical operation on 25.11.2015. The photocopy of certificate issued by Dr. Dalui on 18.2.2016 shows that Dr. Dalui has opined that the complainant was suffering from excessive bleeding but in the year 2013 the complainant was completely free of disease and all investigations were within normal limits and there was no pre-existing disease. The complainant by adducing evidence on affidavit has stated that Dr. Dalui issued said certificate on 18.2.2016. The contesting O.P. by adducing evidence has not denied such statement of the complainant. As the O.P. No.1 & 2 has brought the case that there was pre-existing disease at the time of inception of the policy and the complainant is not entitled to get relief under policy exclusion clause-4.1, the burden of prove lies upon the O.P. No.1 & 2 to prove such case. The photocopy of the prescription dated 21.3.2011 does not support the claim of the contesting O.Ps. The discharge certificate shows that the complainant was undergone surgical operation for her disease Menorrhgia and Thick Endomented. The certificate issued on 18.2.2016 and the prescription dated 21.3.2011 issued by Dr. Dalui do not support that the complainant had been suffering from Menorrhgia and Thick Endomented since 21.3.2011. As the complainant was medically treated on 21.3.2011 by Dr. Rabindra Nath Dalui, only on such basis it could not be said that the patient was suffering from Menorrhgia and Thick Endomented since 21.3.2011. The materials on record supports that the O.Ps. intentionally on false pretext denied the claim of the complainant and has issued a letter repudiating the claim of the complainant. For this act of the O.Ps. the complainant has suffered mental pain and agony. So, the O.Ps. jointly and severally are liable to pay the actual cost of treatment with interest and to pay compensation for mental, agony and harassment to the complainant. To get relief the complainant has been forced to come before this Forum. So, the complainant is also entitled to get the litigation cost. Considering the fact and circumstances of this case we are of the opinion that Rs. 5,000/- as compensation and Rs. 1,000/- as litigation cost will meet the ends of justice. In view of the above the case succeeds.
Fees paid is correct. Hence, it is
Ordered
that the C.C. Case No. 47of 2016 is allowed on contest against the O.P. Nos. 1&2 and exparte against the rest,
that the complainant do get an award directing O.Ps. jointly or severally to pay Rs. 30,000/- with interest @ 9% p.a. thereon from the date of filing this complaint up to the date of realization, to pay Rs. 5,000/- as compensation and to pay Rs. 1,000/- as litigation cost to the complainant within 45 days from this day failing which the entire awarded amount will carry interest @ 12% p.a. and the complainant will be at liberty to put this award in execution in accordance with law.
(Asoke Kr. Mandal)
Dictated and corrected by me, President
D.C.D.R.F., Burdwan
(Asoke Kr. Mandal)
President (Pankaj Kr. Sinha)
D.C.D.R.F., Burdwan Member
D.C.D.R.F., Burdwan
