P R E S E N T
Hon’ble President : Shri B. D. Nanda, M.A. ( double ), L.L.M., WBHJS.
Hon’ble Member : Smt. Jhumki Saha.
Hon’ble Member : Shri A.K. Pathak.
F I N A L O R D E R
- Complainant, Sri Sibnath Ray ,since deceased, substituted by his wife, smt. Ratna Ray, by filing a petition U/S 12 of the C .P. Act, 1986 ( as amended up to date ) has prayed for a direction to be given upon the o.p. to pay Rs.1,10,000/- towards damages and compensation and Rs.20,000/- as litigation cost along with other relief or reliefs as the Forum may deem fit and proper.
- Brief fact of the case is that complainant’s husband took one mediclaim policy from O.P. for which O.P. issued policy document vide annexure ‘A’ for the period 11/05/2011 to 10/05/2012 on payment of requisite premium amount being Rs.4365/- and the said policy was renewed on the due date for a period from 11/05/2012 to 10/05/2013 vide annexure ‘B’ on payment of Rs.6830/- for which O.P.. issued policy document having no 311700/48/2013/373. During this policy period, complainant’s husband had to be hospitalized on 05/07/2012 for which O.P. settled the claim for an amount of Rs.22,145/- vide annexure ‘C’. In the same policy period, complainant had to be hospitalized again on 06/09/2012 for the same treatment as was done in his first hospitalization i.e. for the treatment of Therapeutic Paracentisis and he submitted the claim for an amount of Rs.41153/- vide claim no. 2483679 dt. 25/09/2012. Before that he had to go to CMC vellore for the same treatment from 16/08/2012 to 23/08/2012 and he had to incur an expenditure to the tune of Rs.51587/- vide annexure ‘F’ and he submitted his claim being no. 2483702 on 25/09/2012 for an amount of Rs.50,779/- vide annexure ‘G’. But OP repudiated both these claims on the ground that since both the claims arose in the second year after the inception of the policy in question, claims could not be allowed as the complainant was admitted for the diseases which fall under the exclusion clause in case of a second year running policy vide annexure ‘H’. It is also alleged that at the time of inception of the policy in question in 2011, the prospectus of the O.P. did not reveal this exclusion clause. And it was not even communicated to him at the time of renewal of the police in 2012. Moreover, when O.P. admitted and allowed the first claim, for the same treatment in the same second policy year, O.P. should not have repudiated the same. Accordingly, alleging deficiency in service, complainant filed this instant case with the aforesaid prayers.
- Notice was served upon O.P. O.P. appeared and filed W/V. So, the case was heard on contest.
- Upon pleadings of both parties two points arose for determination :
i) Is there any deficiency in service on the part of the O.P. ?
- Whether the complainant is entitled to get any relief as prayed for ?
DECISION WITH REASONS :
- We have carefully W/V and affidavit in evidence filed by O.P. and noted their contents. It is admitted by O.P. that at the time of taking policy in 2011, complainant was aged about 67 years. Still they did not care to have the complainant’s premedical check up report before giving him mediclaim policy which clearly shows that they are only interested to get the premium amount from the customers like complainant here in. They have also taken a plea that complainant was suffering from Right Kidney carcinoma along with Decompensated chronic liver disease, Refractory Ascities since 2006 and it was endorsed by CMC Vellore in their discharge summary dt. 16/08/2012 to 23/08/2012 and he was again admitted in a hospital in Kolkata on 06/09/2012 for the same aforesaid disease. And by way of suppressing these material information, he took mediclaim policy in the year 2011 and subsequently he could succeed to get his first claim of Rs.22,145/- although he was hospitalized for the same above disease. We have carefully gone through all discharge summaries given by different hospitals and arrived at an opinion that complainant’s husband was hospitalized for the same treatment from 05/07/2012. It was the duty of the O.P. to send him for a medical check up before giving him the mediclaim policy. At the time of giving policy and taking the premium from the customers like the complainant’s husband, O.P. remained careless and at the time of releasing claim amount, they are becoming very careful, this is not acceptable. People take a mediclam policy forseeing all future medical expenditure. O.P. should have been far more careful at the time of inception of the policy, which started at the age of 67 of the complainant’s husband. O.p should remember that a person of 67 may not be a healthy one in all respect, So, they ought to have sent him for pre-medical check up. But they did not care to do that. Even they renewed the policy without a medical test report. And at the time of reimbursement, they are taking the plea of pre-existing disease which is nothing but an unfair trade practice. Accordingly, we are of candid opinion that it is a fit case where the prayers of the complainant should be allowed.
Hence,
O R D E R E D
That the C. C. Case No. 665 of 2014 ( HDF 665 of 2014 ) be allowed on contest with costs against the O.P.
That the O.P. is directed to pay Rs.91,932 to the complainant, being the claim amount.
That the O.P. is further directed to pay to the complainant an amount of Rs.5000/- as compensation and Rs.2000/- as litigation costs.
That the o.p. is directed to pay the entire amount of Rs.98,932 /- to the complainant within one month from the date of this order i.d., the aforesaid amount shall carry an interest @ 8% per annum till full realization.
The complainant is at liberty to put the decree into execution after expiry of the appeal period.
Supply the copies of the order to the parties, as per rule.
DICTATED & CORRECTED
BY ME.
( Jhumki Saha )
Member, C.D.R.F., Howrah.
