Present : Sri A.K. Das, President
Sri L.K. Banerjee, Member
Smt. J. Saha, Member
Order no. 8 dt.11.04.2008
The present case being no.346/2006 was filed u/s 12 of the C.P. Act, 1986 by Sri Kanailal Chanda, S/o Late Lal Behari Chanda, G-311, Baghajatin, Kolkata-86 against the o.ps. viz (1) Royal Sundaram Alliance Insurance Co. Ltd., 21, Patllos Road, Chennai 600 002 and corporate office at “Sundaram Towers”, 45 & 46, Whites Road, Chennai 600 014 and Eastern Regional office at “Shubham”, 1st Floor, Block 101-103, 1 Sarojini Naidu Sarani, P.S. Shakespeare Sarani, Kolkata-17 (2) Assistant General Manger, Royal Sundaram Alliance Insurance Co. Ltd., “Sundaram Towers”, 45 & 46 Whites Road, Chennai 600 014 and (3) Executive Claims, /Royal Sundaram Alliance Insurance Co. Ltd., “Sundaram Towers”, 45 & 46 Whites Road, Chennai 600 014 before the forum praying for various relief as specified at page 8 of the main petition.
The facts of he case are in brief as follows :
That the complainant along with this daughter and son in law took mediclaim policy popularly known as Health Shield Plan with the o.ps. The policy number was HLSBIL 0008 and certificate number was HS000082040000100. The policy was foir the period from 12.6.04 to 11.6.05. That the complainant feeling pain in stomach, took admission on 8.11.04 in Woodlands Medical Centre Ltd. thee he was operate upon, treated and discharged on 19.11.04. Towards treatment he spent Rs.92,443/-. The complainant submitted insurance claim with the o.ps. and the o.p. no.3 intimated its decision on 7.1.05 stating interalia that complainant arising from pre-existing disease will be considered part of that pre-existing condition. Therefore the o.ps. are unable to consider the claim on the above cited ground. The claim was repudiated on the pre-existing condition.
The complainant requested the o.ps. to reconsider its decision and settle the claim but it was all in vain. The petitioner relied upon the annexure marked A-G in support of his claim. Hence this case is before he forum.
The o.ps. have been contesting he case all along by filing w/v supported by affidavit denying therein very emphatically the material allegation of the petition of complaint.
The o.ps. stuck to their decision and explained in their affidavit in detail under which condition they repudiated the claim of the petitioner. It was done on the basis of he pre-existing disease.
Fact reveals that the petitioner was a policy holder, took admission in the nursing home for treatment and incurred expenditure to the tune of Rs.92443/-.
It appears from the record that the policy holder has no knowledge about any disease which he was taking up the policy with the o.p. O.ps. took no effort to check up the policy holder while issuing mediclaim policy.
If the pre-existing condition is to be taken into consideration it would help the o.p. insurance company to wash off their hands in every case. Hon’ble National Commission observes that the insurance company could never be held liable to pay any claim because every person suffers symptom of same or other disease without knowing of it. This makes an insurance policy nothing but a contract to accept a premium without any bona fide intention of giving any compensation to the insured.
Moreover in an appeal no.A111 of 2003 dt.12.12.05 Hon’ble State Commission, Delhi held that ‘unless and until patient has undergone long treatment including hospitalization and undergoes operation etc in near proximity of taking policy cannot be accused of concealment of material fact.
Here, the policy holder tok policy on 12.6.04 and discharged from hospital after operation on 19.11.04. There is no material to suggest that the policy holder while taking up the policy concealed material fact regarding his pre existing disease. Having considered all the material facts perused documents, judgments furnished by the parties and submission made by the parties, the forum is of the opinion that the o.ps. action smacks of dereliction of duty and deficient in service as the o.ps. failed to render necessary service in settling the claim of the policy holder. The policy holder has been able to prove his case to the hilt so as to get the benefit within the ambit of the C.P. Act, 1986. The case succeeds on contest.
Hence,
Ordered,
The o.ps. are directed to pay the claim amount of the policy holder amounting Rs.92,443/- (Rupees ninety two thousand four hundred forty three) only incurred by the policy holder towards his treatment and the o.ps. are also directed to pay a sum of Rs.3000/- (Rupees three thousand) and Rs.1000/- (Rupees one thousand) respectively only as compensation and litigation cost for causing needless mental agony harassment to the policy holder through its negligence, inaction and deficiency. The payment should be made within 60 days from the date of this order , failing which it will carry interest @ 8% p.a. from the date of this order till realization.
Let copy of this order be supplied to the parties free of cost.
Member Member President
