In the Court of the
Consumer Disputes Redressal Forum, Unit -I, Kolkata,
8B, Nelie Sengupta Sarani, Kolkata-700087.
CDF/Unit-I/Case No.70/2011
1) Narendra Chindalia,
C/o. Howrah Blue Print (Opp. Tibre World),
1, Bhajan Lal Lohia Lane, Howrah-711101 ---------- Complainant
---Versus---
1) Reliance General Insurance Co. Ltd.,
Himalaya House, 5th Floor,
38B, Jawahar Lal Nehru Road, Kolkata-71,
P.S. Shakespeare Sarani and its policy issuing
Branch office situated at
49, Debson Road, 2nd Floor, Pin-788710. ---------- Opposite Party
Present : Sri Sankar Nath Das, President.
Dr. Subir Kumar Chaudhuri, Member
Order No. 17 Dated 10/10/2012
The petition of complaint has been filed by the complainant Narendra Chindalia against the o.ps. Reliance General Insurance Co. Ltd. The case of the complainant in short is that complainant had purchased one mediclaim policy as ‘Reliance Health Wise-Gold Plan Policy’from Reliance General Insurance Co. Ltd. having its Branch Office at 49, Dobson Road, 2nd Floor, Howrah-711101 through an agent of the insurance company. The special feature of the Gold Plan Policy was pre-existing expenses are covered from the 3rd year of the policy after two continuous renewals of this policy with the company. Complainant says that he has bought services of insurance coverage by payment of higher amount of premium from the insurance company with a promise to make good the expenses in case of incurring expenses on hospitalization of the insured persons even pre-existing expenses from the 3rd year of continuous renewed policy. Insurance policy between the insurer and the insured represents a contract between the parties.
Complainant bought a Gold Plan-Reliance Health Wise Policy from the o.p. Reliance General Insurance Co. Ltd. for mediclaim health insurance coverage for himself and also for his wife for a sum insured of Rs.2 lakhs each for the period from 18.3.08 to 17.3.09 under policy no.282530009884 (annex-1) and thereafter it was renewed without break for the period from 18.3.09 to 17.3.10 vide policy no.28253000988401 (annex-1). This policy was also renewed continuously for the 3rd year without break for the period 18.3.10 to 17.3.11 vide renewed policy no.1503792825001662 (annex-3). On each renewal the insurance company appreciated for choosing their Health Wise Insurance Policy as the said policy waived the pre-existing diseases. This policy shall provide for payment of hospitalization expenses for treatment relating to pre-existing diseases, illness, injury from the 3rd of the policy after two continuous renewals or from the 5th year of this policy after 4 continuous renewals, as the case may be, subject to this plan poted.
Complainant consulted with his physician Dr. M.L. Bhansali on 24.5.10. It is clearly be observed that B.P. of complainant was 150/80 mm. of Hg and it was within normal limit. Further on 25.5.10 he consulted with the Dr. Jayanta Basu of Shree Jain Hospital & Research Centre, Howrah on the advice of Dr. Bhansal, the OPD. Ticket shows that the blood pressure of complainant was 140/80 mm. of Hg. (Mercury). This B.P. was also within normal limit but the said OPD Ticket dtf.25.5.10 written as HTN-10 years. The complainant states that he had said to the doctor Jayanta Basu during his consultation in OPD that he had some dizziness / vertigo due to his business troubles say for last 10 years but the doctor has written in OPD ticket ‘HTN 10 yrs’. The patient did not know what the doctor had written in the OPD ticket. Complainant states that he had not taken any medicines or suffered any such serious disease before having the present ailment.
Complainant took admission in the Shree Jain Hospital, Howrah on 25.5.10 and was discharged from the said hospital on 4.6.10. Complainant lodged his mediclaim under the policy to the TPA, a claim settling agent of the insurance company, Medi Assist India Pvt. Ltd. for a sum of
Rs.66,065/- on 30.6.10. TPA on behalf of the insurance company wrote a letter to the insured complainant seeking a certificate from a treating doctor. Since Dr. Jayanta Basu did not wish to furnish any certificate saying that he was first consulted by the patient on 2.5.10. Complainant then consulted with his family physician Dr. M.L. Bhansali who has given a certificate on 29.7.10 saying that the patient consulted him with H/O Hypertension for 6 months with weakness and breathlessness. He was found to have chronic renal failure on 24.5.10 for which he was advised to consult Nephrologist. He was not having any previous medical records. Complainant sent this certificate to the above named TPA.
Complainant received a letter dt.4.8.10 from TPA Medi Assist against claim no.5136035, MAID no.4004717432 under Policy no.1503/792825001662 saying that “the patient is having H/O of Hypertension since 10 years as per prescription dt.25.5.10… The HTN is pre-existing disease and not declared in the policy proposal from while taking the policy. Hence the claim was denied as per policy terms and condition s clause 2 due to non-disclosure of fact in proposal.
As advise by TPA to lodge appeal to the insurance company, complainant wrote a letter dt.29.9.10 to the insurance company / o.p. followed by a reminder dt.11.11.10 when o.p. vide their letter dt.23.11.10 written on the same line that the patient was suffering from Hypertension for last 10 years but at the time of inception of the policy (HTN) was not mentioned in the proposal form and hence the claim is declined. Hence the case was filed by complainant with the prayer contained in the prayer portion of the petition of complaint.
O.p. had entered its appearance in this case by filing w/v and denied all the material allegations labeled against it. O.p. in the w/v has stated that all the available documents submitted by complainant it has been revealed that in the OPD ticket dt.25.5.l0 it has been clearly written that complainant has been suffering from HYPERTENSION since last 10 years but at the time of inception of the insurance policy said disease had not been willfully mentioned in the proposal form. Ld. lawyer of o.p. in the course argument has stated that the instant case is not maintainable and the same is liable to be dismissed.
Decision with reasons: -
We have gone through the pleadings of the parties, evidence and documents in particular. It is an admitted position that complainant purchased mediclaim policy as Reliance Health Wise Gold Plan Policy from o.p. and it also covered insured persons for the expenses incurred by them on hospitalization even of pre-existing disease expenses 3rd year of continuous renewed policy. But surprisingly enough repudiation was on the ground non disclosure and on suppression material fact in the proposal form though the same was well within the knowledge of complainant. That apart o.p. in reply vide answer 3 has admitted that the claim has not been repudiated on the ground of pre-existing disease.
In view of the above position it is highly ridiculous that o.p. repudiated the claim in an escapist manner quoting non disclosure of fact although o.p. in renewed policy from 3rd year onwards waived the clause of preexisting disease. We find no justification denying the claim of the complainant by way of repudiation of the claim b y o.p. and this act on the part of o.p. amounts to gross negligence and deficiency in service being a service provider to its consumer / complainant and complainant is entitled to relief.
Hence, ordered,
That the petition of complaint is allowed on contest against the o.p. with cost. O.p. is directed to pay claim of complainant for Rs.92,206/- (Rupees ninety two thousand two hundred six) only together with interest @ 9% p.a. from the date of repudiation till the date of realization and is further directed to pay compensation of Rs.25,000/- (Rupees twenty five thousand) only for harassment and mental agony and litigation cost of Rs.5000/- (Rupees five thousand) only within 45 days from the date of communication of this order, i.d. an interest @ 9% shall accrue over the entire sum due to the credit of the complainant till full realization.
Supply certified copy of this order to the parties free of cost.
