Order-20.
Date-28/07/2015.
This is an application u/s.12 of the C.P. Act, 1986.
Complainant by filing this complaint has submitted that OP1 is the Insurance Company soliciting general insurance business within the territory of India and the OP2 is the third party administrator and working for the OP1.
Complainant herself, her husband Subrata Kumar Hati and son Shambo Hati were insured under Happy Family Floater Policy of the OP1 which is a mediclaim policy being Policy No.311200/48/2013/2756 for the period of 24-09-2012 to 23-09-2013 and under the said policy the complainant and his family members covered for sum assured of Rs.3,00,000/-. On 16-03-2013 complainant visited Dr. Mrityunjay Mukherjee with a complain of Pedunculated Lipoma left thigh and Dr. Mukherjee on 20-03-2013 advised the complainant for admission at Nigthtingale Hospital for necessary operation and on 29-03-2013 complainant admitted at Nightingale Hospital where Dr. Mukherjee done necessary operation and she was discharged from there on 30-03-2013 with stable condition. Complainant spent Rs.23,000/- towards medical bill during and after hospitalization and through her son Shambo Hati raised a claim before the OPs1 and 2 but OP1 vide its letter dated 25-08-2013 repudiated the genuine claim showing a whimsical ground of Exclusion Clause 4.10 that …….. “the claim stands non-admissible because it could have been possible on an OPD basis.”
It is humbly submitted that it is not possible for a patient who is suffering from a certain illness to avoid the advice of a specialist doctors. Dr. M Mukherjee who advised the complainant to get admitted at Nightingale Hospital and the complainant has followed the advice of her treating doctor. OPs have deliberately avoided the genuine claim of the complainant without any cogent reason and on whimsical ground for which complainant is compelled to file this complaint before this Forum for the deficiency and unfair trade practice of the OPs and prayed before Forum for redressal, compensation etc.
On the other hand, OP by filing written version admitted that the complainant is an insured under Happy Family Floater Policy being Policy No.311200/48/2013/2756 for the period from 24-09-2012 to 23-09-2013 for the sum assured of Rs.3,00,000/- and on 29-03-2013 complainant admitted at Nightingale Hospital under Dr. Mrityunjay Mukherjee for the necessary operation of Pedunculated Lipoma left thigh and this current illness Pedunculated Lipoma left thigh was existing prior to taking of the policy which the complainant was aware of but not disclosed at the time of taking the policy. Therefore, the claim was repudiated under Exclusion Clause of 4.10 and for which the complaint is liable to be dismissed.
Decision with Reasons
On an indepth study of the complaint and the written version and also after considering the argument as advanced by the Ld. Lawyer of both the parties and further relying upon the letter of Senior Divisional Manager of the OP dated 25-08-2013 it is found that the claim of the complainant was repudiated as per Exclusion Clause 4.10 on the basis of the final report of the TPA Services to whom the complainant lodged the mediclaim.
In fact, complainant’s grievance is that complainant was admitted to Nightingale Hospital as per advice of Dr. Mrityunjay Mukherjee on 29-03-2013 at 8.36 a,m. and she was discharged on 30-03-2013 at about 10-00 a.m. after Excision biopsy taken under L.A. on 29-03-2013 for pedunculated lipoma of left thigh and from discharge summary of Nightingale Hospital it is clear that on diagnosis it is detected it is a case of pedunculated lipoma of left thigh Excision biopsy taken under L.A. About admission and about the course as taken by the doctor in hospital are not denied. Fact is that complainant submitted detail bills along with claim form and discharge summary and no doubt as per final bill dated 30-03-2013 it is clear that complainant paid an amount of Rs.20,568/- to the said hospital at the time of discharge for his admission and for taking such course in the said hospital by the doctor.
It is undisputed fact that complainant purchased this policy that is Happy Family Floater Policy and insured names are Sikha Hati, Subrata Kumar Hati and Shambo Hati who are covered by the insurance policy being no.311200/48/2013/2756 for the period 24-09-2012 to midnight of 23-09-2013 and basic coverage is Rs.3 lakhs and along with that policy there was terms and condition attached with that policy which has been filed by the complainant and from that policy it is found that in Clause 4.1 any Pre-existing health condition or disease ailment or injuries the insured is not entitled to get any benefit of the mediclaim up to 4 years from the date of purchasing this policy and in the present case complainant has not claimed that their policy is a continuous policy with renewal for continuous four years having no claim and in view of the fact it is clear that complainant is not entitled to get any benefit of mediclaim if it is found that there is any pre-existing disease as per Clause 4.1.
Anyhow, the Ld. Lawyer for the complainant tried to convince that suddenly he found a swelling on the thigh in a particular area so, she went to Dr. Mrityunjay Mukherjee who advised her to admit in the present hospital and as per his advice she was admitted and more than 24 hours she was hospitalized and Excision on the particular area were made and doctor collected excision biopsy under L.A. and on diagnosis it is detected that the same is pedunculated lipoma of left thigh and in fact, that course of action as taken by the doctor was made in between the period 29-03-2013 at 8.36 a.m. to 30-03-2013 at 10.00 am. and she was discharged from Nightingale Hospital.
In fact in this case OP has specifically has taken such defence that it was a pre-existing disease that was suppressed only for the purpose of taking such mediclaim amount this policy was opened and only for the purpose of taking benefit of the mediclaim policy they intentionally with full knowledge suppressed the fact that she had been suffering from pedunculated lipoma of left thigh.
Anyhow, complainant has not stated anywhere for how many years or months she has been suffering from such disease. In this regard OP submitted that complainant herself has admitted that she had been suffering from the said disease for last one year and that has been stated by the complainant in the application for mediclaim submitted to the OP. So, in this regard we have gone through the copy of mediclaim form submitted by the complainant’s son and it is found that where complainant herself noted in the said application form that she had been suffering from said disease for last year from the date of action as taken by the hospital that is on 29-03-2013 that means complainant has been suffering from said disease since 28-03-2012 and ultimately on 29-03-2013 excision biopsy was taken by the doctor. But anyhow at the time of filing application for purchasing the mediclaim policy complainant did not disclose of this fact that she had been suffering from said disease since 28-03-2012 and in this regard we have gone through the policy copy wherefrom it is found that policy was purchased on 24-09-2012 whereas the lady had been suffering from said disease prior to purchasing the policy that was not disclosed.
Most interesting factor is that complainant Sikha Hati filed the medical report and also the claim form and it is also noted in claim form that she has been suffering from pedunculated lipoma of left thigh for last one year so, it is clearly proved that the complainant the insured and her husband and son at the time of purchasing the policy suppressed the health condition of the present complainant though in the mediclaim application form it is specifically stated that it is a chronic disease by the insured so, it is clear that it was a pre-existing disease of that was suppressed by the complainant and other insured at the time of purchasing the policy in the name of Sikha Hati and other when that is the fact then it can safely be said that as per judgment of the Hon’ble Supreme Court, National Commission suppression of fact at the time of taking the policy is a ground for not to entertain any claim and when there is a specific provision in the terms and condition that is Clause 4.1 that in respect of any treatment or operation or for any other cause no insured shall get any benefit of the mediclaim policy and in this regard National Commission by its judgment passed in CPR 2013(4) page 165 observed that policy condition shall be strictly followed by the Forum and no explanation or relaxation can be made on the ground of equity and at the same time for violating the terms and condition of the policy complainant is not entitled to get any relief. But most interesting factor is that Sikha Hati answered against queries made by the OP that during policy period illness occurred but it is clearly false version because in the mediclaim application form it is specifically mentioned that she was suffering from the disease for last one year prior to such excision biopsy taken by the doctor on 29-03-2013. So, the answer as given by the complainant against queries of the OPs is also false and fabricated. Anyhow, in the repudiation letter it is noted Clause 4.10 by clerical mistake but it would be noted 4.1 for which invariably complainant cannot get any relief.
Considering all the above facts and also the judgement passed by Hon’ble Supreme Court reported in 1966 (1) CPR 22 NCDRC we are inclined to held that the repudiation as made by the OP is quite justified and it was done by application of mind and also applying the condition and also its fact so OPs rightly pointed out and brought such plea that it was pre-existing disease which has been admitted by the complainant and her son in the mediclaim application form
In the light of the above observation the complaint fails.
Hence,
Ordered
That the case be and the same is dismissed on contest against the OPs but without any cost.
