JUDGEMENT

          The complainant’s simple case is that complainant and Pinky Dey (since deceased) were jointly policy holder bearing No.311500/48/2010/2741 dated 2006 and practically the complainant and Pinky Dey opted for their family medical policy from op no.1 in the names of Purnima Dey after renewal of every year for total sum of Rs. 30,000/- respectively bearing policy No. 311500 dated 2006 and complainant had been regularly paying the yearly premium to the full satisfaction of the op no.1 against receipt of renewal policy in support of the same.

          It was cashless medical policy payable to the complainant on claim being lodged in the event that complainant and/or her family members being admitted to the hospital or being undergoing any treatment for any sickness as have been stipulated in the said policy.  Sometime in the year of 2007 the complainant’s only daughter namely Pinky Dey (since deceased) being a co-policy holder under the said medical policy having date of birth 07.07.1983 became seriously ill and so medical checkup and tests were made and it was revealed that she was suffering from some disease for which she was under treatment of Dr. Goutam Majumdar.  But prior to opening of the said policy or renewal of the policy, she never had any health related problems and she never suffered from any pre-existing disease or infection.  But sometime in the year of 2010, when suddenly Pinky Dey (since deceased) suffered from Chronic Kidney disease so regular treatment was initiated for her.

          During the passage of time, Pinky Dey had to undergo various medical tests but suddenly on 31.03.2010 when her health condition deteriorated she was admitted to Calcutta Medical Research Institute, Kolkata under supervision and treatment of doctor of the said hospital.

The complainant at the time of admission of Pinky Dey (since deceased) could not deposit the policy and connected documents before Calcutta Medical Research Institute, Kolkata and as a result of the same the complainant and her sons arranged funds and had been continuing with the treatment of Pinky Dey.  But unfortunately on 01.04.2010 Pinky Dey expired during course of treatment at Calcutta Medical Research Institute, Calcutta and for her treatment expenses complainant had spent Rs.36,547/- towards the medical expense of Pinky Dey and for her death, complainant was mentally shocked.  So, on 27.05.2010, the complainant lodged a claim against the said mediclaim policy before the op no.1 for refund of the entire sum of money what the complainant had incurred towards treatment of her only daughter and at the time of lodging the claim he filed all necessary medical documents and other medical bills and reports which was issued by the said hospital and same was lodged before the op no.1 and op no.1 appointed op no.2 as its agent  to adjudicate the said claim but op no.2 by a letter dated 21.07.2010 called upon the complainant to provide with copies of “Treating doctor to state the commencement of ailments and all past prescriptions” for settling the claim without any delay.

Fact remains that long after 7 months, op no.2 by their alleged letter dated 23.02.2011 repudiated the claim though complainant fulfilled all formalities and required documents related to medical papers and treatment in original and op no.2 admitted that they received all medical documents which were required for settlement of the same but ultimately repudiated the claim without any valid reasons.  Practically there was no basis or reason for repudiation of the claim and it was made illegally and for which complainant appeared before this Forum for redressal.

On the other hand op by filing written statement submitted that no doubt complainant and Pinky Dey were covered by Mediclaim Policy and TPA is its authorized signatory of company deals with the claims under Mediclaim Policy regarding reimbursement and cashless claim.  But it is specifically mentioned that complaint is not maintainable in the eye of law and entire allegations are false and fabricated.  But it is specifically stated that complainant has specifically mentioned that various checkup and tests were done during treatment of Pinky Dey and invariably nature of disease was discovered.  But complainant did not disclose at all but only complainant has completed the sentences adding one word “some disease” which is not believable.

Though complainant has tried to say that Pinky Dey had no health related problem since her childhood and Pinky Dey never suffered from any disease etc.  but fact remains Pinky Dey died on 01.04.2010 and op is very much sympathetic with the parents due to sudden demise of Pinky Dey due to pre-mature death of only daughter but law is above sympathy on the ground that Insurance Policy is a bilateral contract between the insurer and insured and at the time of taking the policy the insured was fully aware about the clauses and in the present case final claim along with hospital receipts, original bills, cash memo reports claim from list of documents as listed were not submitted by the complainant to the op as per requirement of TPA Authority though several time requested the complainant vide their letter dated 21.07.2010 and 23.02.2011 to produce all documents made by the doctors and about all past prescriptions, complainant did not honour and the requests of the TPA were not honoured by the complainant and as because op did not file those papers for which TPA authority ultimately repudiated the claim and closed the file so the ops are not liable for any repudiation.  But repudiation was made for non-compliance of the requirement as per policy condition.  So, the entire complaint is frivolous and fabricated.

 Further it is submitted that the documents which were received by the ops from the complainant revealed that Pinky Dey died due to her pre-existing disease and for which the complaint should be dismissed.

                                       Decision with reasons

On careful consideration of the argument as advanced by the Ld. Lawyers of both the parties and also considering the documents as submitted by the complainant, it is found that on 24.12.2007 Pinky Dey  aged about 24 years was examined by Dr. Goutam Majumdar at Nitingle Diagnostic Medical Research Centre Pvt. Ltd. and at that time after tests it was detected that she had been suffering from Hypertensive Returopathy and at that time her blood pressure range was 190/120 and more over she had been suffering from Urinary problem and Oral Ulcer.  But fact remains TPA sent letter to the complainant on two occasions for supplying the information of the treating doctor about the commencement all the ailments and all past prescriptions but complainant did not send it.  What is proved.  After considering the policy Anexure-A, it is clear that sum assured was Rs.30,000/- and domiciliary hospital limit was Rs.6,000/- and cumulative bonus was Rs.1,500/- and the first policy against which the claim was made, was valid for the period from 21.07.2003 to 20.07.2007 and admitted fact is that Pinky Dey died on 01.04.2010 and her date of birth was 07.07.1983 and she was admitted to present hospital on 31.03.2010 and in fact from 31.03.2010 to 01.04.2010 she was hospitalized in the present hospital for treatment and practically for 5 days she was in the hospital.  But admitted position is that complainant continued the policy up to 2010 that means the policy continued for 4 years. As per policy condition if any Mediclaim Policy is renewed for more than 4 years preceeding to last claim, in that case in respect of pre-existing disease also any claim must be satisfied by Insurance Company.  But in this case, it is found that this policy was started on 21.07.2006 and every year i.e. between 21.07.2006 to 20.07.2010 the policy was renewed and admitted fact is that the last policy was valid from 21.07.2009 to 20.07.2011 and in between the existence of the said policy Pinky Dey died on 01.04.2010.  So, it is clear that complainant’s daughter died when such renewed policy was valid.  It is also proved that continuously for 4 years, the policy was regularly renewed. 

So, for 4 years policy was continued by the complainant covering the medical risk of Pinky Dey, premiums were paid.  But op has refused the claim on the ground that complainant did not send some required documents as called for by the TPA to the complainant.  Fact remains that complainant received but did not submit and in the complaint complainant has suppressed it.  But fact remains that always sum assured was Rs.30,000/- and cumulative bonus is Rs.1,500/-.  So, in respect of total claim complainant is not entitled to more than Rs.31,500/-.  But truth is that complainant did not send the material documents to the op for which it was requested by the op to submit it.

Truth is that Pinky Dey died at the age of 24 years but since 2005 she had been suffering from Hypertension which is evident from the document that is prescription issued by Dr. Goutam Majumdar on 14.12.2007 and from that prescription it is clear that Pinky Dey had been suffering from Hypertension since 14.12.2007 and she had been suffering from Urinary problem with some oral ulcer.  But complainant has suppressed it that means prior to opening of the first policy in the year 2006 Pinky Dey has been suffering from Hypertension (Hypertensive Returopathy). 

So, it is clear that complainant suppressed the fact of pre-existing disease of his daughter Pinky Dey at the time of opening the Mediclaim Policy.  Moreover complainant at the time of year to year renewal did not disclose the same.  Another factor is that complainant did not submit before this Forum the copy of the treatment sheet in between the period from 31.03.2010 to 01.04.2010 and also death certificate issued by the hospital and fact remains that in several juegements of Delhi High Court observed in AIR 2008 Delhi 29 that Caluse 4.1 is very clear as what kind of diseases were covered by Mediclaim Insurance Company and the definition of pre-existing condition included sickness or symptoms that existing prior to the insurance policy regardless of knowledge of the insurer and it is included complications arising out of the pre-existing disease and conditions and Delhi High Court also came to conclusion that giving effect of clause 4.1 would in most such cases render the mediclaim cover meaningless and the policy would be reduced to a contract with no content, in the event of the happening of the contingency and hold that refusal by the insurer to process and reimburse is arbitrary and unreasonable; as a state agency, it has to set standards of model behavior; its attitude here has displayed a contrary tendency and a direction is issued to the op to process the complainant’s claim and in that case to process the claim and further another ruling reported in 1999 (3) CPR 275 also supports that when complainant incurred expenses it is must for the insurance company to give relief and further we rely upon another ruling reported in 2006 CPR 295 (NC) and after consideing present circumstances and above ruling we are convinced to hold that in the present particular policy in the present case op ought to have release the claim up to Rs.31,500/- as sum assured and cumulative bonus considering the entire aspect of the claim.  But anyhow op repudiated the claim.

In the present particular case some amount ought not to have been allowed in view of the sad demise of Pinky Dey but truth is that for 4 years policy was continued and exception clause 4.1 should not be implemented in the present case and considering the whole aspect and the materials, we are allowing the complainant by directing the op to pay a sum of Rs.31,500/- as final settlement of claim of the complainant in respect of the claim as made by the complainant to the op. and no doubt complainant has some fault.

But even then the op ought to have considered the same after collecting the same from the said hospital authority by sending such queries but that had not been done by the op.

In the result, the complaint succeeds.

Hence, it is

                                              ORDERED

That the complaint be and the same is allowed on contest with cost of Rs.2,000/- against the op no.1 and same is dismissed against the op no.2 without any cost.

Op no.1 is hereby directed to pay a sum of Rs.31,500/- to the complainant within one month from the date of this order failing which for non-compliance of the Forum’s order and for each day’s delay a sum of Rs.200/- shall be assessed as punitive damages till full satisfaction of the decree and even penal action shall be taken against them for violation and disobeyance of the Forum’s order.

In this case no compensation is awarded in view of the fact that complainant was at fault for not sending all the documents as called for by the ops.