West Bengal

Paschim Midnapore

CC/166/2017

Barun Kumar Samanta - Complainant(s)

Versus

P.N.B. Met Life Insurance Co.Ltd. - Opp.Party(s)

Asim Kumar Dutta

06 Jun 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

PASCHIM MEDINIPUR.

                             

    Bibekananda Pramanik, President

and

     Pulak Kumar Singha, Member

Complaint Case No.166/2017

                                                                  Barun Kumar Samanta, S/o-Late Anukul Samanta,

                                              Station Road, Bhunia Para, P.O.Midnapore, P.S.Kotwali,                                                                                 

                                                                Dist- Paschim Medinipur.  

                                                                                             ………..……Complainants.

                                                                              Vs.

                 P.N. B. Met Life Insurance  Co. Ltd., Kharagpur Branch Office at

     Atwal Real Estate, O.T.Road, at Inda, P.O.Kharagpur,                                                              

          P.S.-Kharagpur (T),  Dist- Paschim Medinipur.

                                                                            .....……….….Opp. Party.                                                    

              For the Complainant: Mr. Ashim Kumar Dutta, Advocate.

              For the O.P.               : Mr. Debasish Maity, Advocate.

                                                          

                                                                                         Date of filling:- 07/11/2017

  Decided on : -    06/06/2018

                               

ORDER

                          Pulak Kumar Singha, Member –In brief the case of the complainant is that complainant purchased one Mediclaim policy namely Metlife major illness policy from O.P. which was renamed upto 10 years from 07/09/2015 by paying premium of Rs.15,144.50/-. On 01/04/2017 complainant suffered from chest pain and  attended to the doctor at Midnapore for treatment,  after examination doctor advised to take better treatment he have go any Super Specialty Hospital, then complainant went to Chennai Apollo Hospital where he was treated by Dr. Robert Mao for heart decease and  complainant  have to spent Rs.10,00,000/-(Ten lakh). After discharge from said hospital complainant submitted claim with all reasonable documents but O.P. repudiated the claim on the ground of exclusion clause. Complainant appeared before this Forum for getting

                                                                                                                                               Contd………………….P/2

 

 

                                                                                               ( 2 )

relief as per prayer of complaint. O.P. contested the case by filing written statement denying the allegations of complainant stating inter alia, that the complaint is false, incorrect and filed with malafide intention, complainant was aware the  terms and conditions of Metlife major illness policy, coronary Artery By-pass surgery did not satisfy the terms of the policy contract  as such O.P. repudiated the claim. O.P. prays for dismissal of the complaint.                                                                                                       

                                                                                 Decision with reasons

                        We carefully perused the complaint, written statement, evidence and documents and it appears that complainant purchased one medical Health Insurance policy which was valid upto 10 years, subject to paid yearly premium of Rs.15,144.50/- and complainant paid first and 2^nd year (renewal) premium. During validity of Insurance policy complainant suffered chest pain and was treated by doctor of Midnapore and after examination of complainant doctor advised for better treatment complainant have to go any Super Specialty Hospital.  Then complainant went to Apollo Hospital at Chennai for his diagnosis and on 04/04/2017 complainant clinically examined by the doctor of said  Hospital and diagnosed Coronary Artery Disease, coronary angiogram (2012) Double vessel disease, system hypertension type 2 diabetes Mellitus. Complainant admitted said Hospital on 25/06/2017 and operated successful PTCA and stetting to LAD done with 3.0x33MM Xience Alpine stent on 26/06/2017. After discharge from the Hospital complainant claimed reimbursement of treatment cost Rs.5,00,000/- (policy assured amount) though complainant has already spent Rs.10,00,000/-. But O.P. repudiated the claim on the ground that definition of Coronary Artery by-pass surgery does not satisfy by the documents submitted by complainant.

To prove his case complainant adduced evidence by filing written examination-in-chief and tendered himself as evidence and also submitted some documents. Complainant was cross examined by O.P. and in cross-examination of O.P.-PW-1 admitted that at the time of obtaining policy I had gone through the terms and conditions of  the policy and he also stated that after repudiation of claim he did not pay any premium. O.P. submitted written argument and stated that O.P.  received the critical illness claim from the complainant where the complainant informed that he underwent Coronory Artery By-Pass Surgery and claimed benefits under the policy  but as per policy condition policy contract open chest CABG are excluded  as :-

1. Angioplasty and/or any other intra-arterial procedure
2. Any keyhole laser surgery.

From the discharge summary (exhibit-4) it reveals that complainant undergone surgery of success ful PTCA and stetting to LAD done with3.0x33MM Xience Alpine

                                                                                                                                                      Contd………………….P/3

 

                                                                                       ( 3 )

stent on 26/06/2017 (Angiography). At the time of argument complainant submitted policy document booklet, in which Appendix-A in the exclusion clause point no.9, it is clearly mentioned that Angioplasty and/or any inter arterial procedures is excluded from the benefit of the policy.  Under such a situation complainant is not entitled to get the policy benefit claim for his medical treatment from O.P. Admitted fact that complainant paid premium of Rs.15,144.50/-   for first year and paid Rs.15,144.50/- for 2^nd year premium as renewal policy. While complainant submitted his claim with all documents, O.P. aught to have consider his claim as per policy condition and paid the policy premium amount to the complainant but O.P. did not perform his duty as a service provider and for such act O.P. is negligent and deficient in service.

Considering the fact of the case, evidence and all documents in the case record we think that as per policy condition complainant is entitled to refund the  policy Premium amount from O.P.  and O.P. is negligent and deficient in rendering service to the consumer rather harassed the complainant for which he is suffering mental  pain and agony as such complainant is entitled to get compensation and other relief.  

                                        Hence, it is,

                                                           Ordered 

                                           that the complaint case be and the same is allowed on contest against the O.P. with cost.

            O.P. is directed to refund back the premium amount of Rs.15,144.50/- to the complainant to pay Rs.5,000/- compensation for harassment and mental pain and  to pay Rs.2,000/- as litigation cost to the complainant within one month from the date of order.

                   Failure to comply the order O.P. shall be liable to pay Rs.2,000/-per month as penal cost to the Legal Aid Fund of this Forum till full realization.

                                    Let plain copy of this order be given to the parties free of cost.

                 Dictated and Corrected by me

                           Sd/- P.K. Singha                                                                          Sd/- B. Pramanik. 

                                 Member                                                                                        President

                                                                                                                                  District Forum

                                                                                                                               Paschim Medinipur