OFFICE OF THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, KAMRUP,GUWAHATI
C.C.55/2008
Present:-
1)Md.Sahadat Hussain, A.J.S. - President
2)Smti Archana Deka Lahkar - Member
Mrs.Geetanjali Hatibaruah -Complainant
W/P Rajiv Hatibaruah
Megh Mallar, App.No. 307,
Zoo Tiniali Rd,Guwahati-34
-vs-
1) Royal Sundaram Alliance - Opp.parties
Insurance Company Ltd.
“Sundaram Towers” 45 & 46, Whites Road,
Chennai-600014, Patallos Road,Chennai-6000002.
2) The Director,
Royal Sundaram Alliance Insurance Company Ltd.
Corporate Claims Department,
“Sundaram Towers” 45 & 46,
Chennai-600014
3) Roshan Anto
Trainee Claims, Royal Sundaram Alliance
Insurance Company Ltd. Corporate Claims Department,
“Sundaram Towers” ” 45 & 46,
Chennai-600014
4) Pratap Thunga, Officer Claims
Royal Sundaram Alliance Insurance Company Ltd.
Corporate Claims Department,
“Sundaram Towers” ” 45 & 46,
Chennai-600014
5) An Authorised agent,
Royal Sundaram Alliance Insurance Company Ltd.
Bajrong Building, Second Floor, Ulubari,G.B.Road,
Guwahati-788007
Appearance-
Learned advocates for the complainant- Ms.Bhabani Devi.
& Mrs.Rituja Dutta
Date of argument- 19.1.2017
Date of judgment- 14.2.2017
JUDGMENT
This is a complaint u/s 12 of the Consumer Protection Act, 1986.
1) The complaint filed by Mrs. Geetanjali Hatibaruah was admitted on 30.5.2008 and notices was served upon all the opp.parties and they also filed a joint written statement. The complainant, in support of her case, filed her affidavit as evidence and she was also cross-examined by ld counsel of opp.parties on 1.12.2010. The opp.party side also filed their evidence through an affidavit of Mr.S.Srinivasan, but after filing of the evidence (affidavit) they defaulted to take step in this case, and accordingly this forum, vide order dtd. 27.6.2013, closed the stage of cross-examination of evidence of opp.parties and fixed dates for filing written argument by the parties. After giving several adjournments to the opp.parties, the opp.parties failed to file written argument as well as also to forward oral argument . Finally, on 25.1.2017, we have heard oral argument of ld advocates Ms.Bhabani Devi, and Ms. Rituja Dutta and today we deliver the judgment which is below –
2) The gist of the pleading of the complainant is that the complainant being the daughter and only legal heir of Late Dr.Jitin Kr.Gogoi ( policy holder) and Late Mrs.Sabita Gogoi (nominee of policy holder) filed this complaint claiming assured money from the opp.parties . The father of the complainant, through Opp.Party No.5, had taken a policy with M/S Royal Sundaram Alliance Insurance Company Ltd. vide policy No. CE/00027253000100 with effect from 4.5.06 to 3.5.07 which was hospital cash insurance i.e. daily benefit of Rs.1500/- in case of hospitalization of the policy holder, and he also had paid full amount of premium to the opp.parties . On 9.10.06 at about 5-30 p.m., her father Late Dr.Jitin Kr.Gogoi felt chest pain and suffered breathing difficulties and rushed to the hospital for treatment and he was admitted in Down Town Hospital and kept in Intensive Care Unit by the doctor, and on the same day, as he did not get relief from the pain and had to stay in the hospital for complete recovery and the doctor diagnosed him as Cerebral Parital Hemorrhage Diabetes Mellitus with Nephropathy, but he had never felt such pain or uneasiness before taking the policy and he had to remain in the hospital for more than one month, although he was in good health before that. He had also been medically examined by the doctor of the opp.parties (insurance companies)at the time of proposal of the insurance policy and was found in good health; and while he was in hospital he himself intimated the opp.parties about his claim for hospitalization and the opp.party side also vide letter dtd. 16.10.2006 asked him to submit the claim form duly filled up along with the discharge summary and other investigation report and he also submitted the said documents accordingly, but unfortunately he expired on 13.11.06 in the Down Town Hospital during hospitalization. The Opp.Party No.4, vide letter dtd.7.12.06, wrote a letter for sending death summary along with requisite documents within 15 days and then her mother sent all the documents including the death summary to the opp.parties . But the opp.party side rejected the claim of the life assured which was intimated, vide their letter dtd. 20.12.06, and wherein they stated stated that claim was repudiated on the ground that the deceased had pre existing disease . The deceased had never been a patient of such disease prior to taking the policy and hence allegation of the opp.party is totally false and baseless. The complainant’s mother sent a representation to the opp.parties on 28.12.2006 for consideration her claim, but the opp.parties did not send any reply to her representation. The complainant’s mother, Mrs.Savita Gogoi, who is the nominee of the policy holder, died on 7.7.07; and on her death, the complainant became a legal heir of the deseased and the policy holder being their only is such (daughter). The complainant served a legal notice upon the opp.parties asking them to pay her compensation of Rs.52,500/-along with interest on the basis of the said policy, but the opp.parties did not reply to the legal notice. As per discharge summary the deseased died due to (RT) Intra Cerebral Parital Hemorrhage Diabetes Mellitus which was recent in origin, but op.parties rejected the claim of the complainant side stating that the deseased had pre-existing diseases. So their act of repudiating the claim of the complainant is a clear case of deficiency of service towards the complainant and hence opp.parties are liable to pay the insured amount to her along with interest.
3) The gist of the pleading of the opp.parties is that the complainant has waived her right to sue by not filing the claim within three calendar month from the date of cause of action i.e.13.11.2006 (date of death of the insured). As per policy condition, the complainant had to file litigation in the court of law within 12 calender months from the date of repudiation but the complainant filed this complaint after three years, and thereby waived her right of claim under the policy . The policy concerned was for the period commencing from 4.5.2006 to 3.5.2007 covering insured for daily benefit of Rs.1500/- The insured on 9.10.2006 after five months from the inception of the policy suffered chest pain and breathing difficulties and was in hospitalizing condition in Down Town Hospital from 9.10.06 to 13.11.2006 and the doctor diagnosed him to have been affected by Cerebral Parital Hemorrhage Diabetes Mellitus and he died on 13.11.2006 and the claim form dtd. 21.11.2006 was submitted by his nominee namely, Mrs.Sabita Gogoi; and then they, on 7.12.2006, asked the said nominee to submit death summary and requisite documents and she had submitted the same. The insured was hospitalized within five months from the inception of the policy and the disease (diabetes Nephropathy) requires long time to develop which could not have developed within five months of inception of the policy and was the disease suffered by the insured was pre-existing disease. The nominee of the insured died on 7.7.2007 . The complaint was lodged without just cause and they are not guilty of any deficiency of service or of committing any negligence. The claim was repudiated after due consideration of valuable documents and on proper ground. The complainant preferred the present complaint only on 24.7.2008 after one year seven months; and therefore , Opp.Party No.2 is not liable to pay any compensation. The complaint is frivolous and without cause of action. The complaint is liable to be dismissed.
4) We have perused the pleadings of the parties as well as their evidence. We have also perused the argument of ld counsels of the complainant side. We have found that it is both sides’ admitted fact that the complainants’ father late Dr.Jiten Kr.Gogoi had done a policy of hospital cash insurance with Royal Sundaram Alliance Insurance Company Limited (Opp.Party No.1) vide policy Certificate No. CE00027253000100 which was effective from 4.5.2006 to 3.5.2007 and the benefit of the said policy is reimbursement of Rs.1500/- per day in the case of hospitalization of the insured . It is also both sides’ admitted fact that in the said insurance, the wife of the complainant Smti Sabita Gogoi was the nominee . It is also both sides admitted fact that on 9.10.06 at 5-30 p.m., the insured was hospitalized at Down Town Hospital with complain of chest pain and breathing difficulties and during the period of hospitalization, the insured himself sent a claim to the opp.parties and Opp.Party No.1 side, vide letter dtd. 16.10.06 (Ext.3), asked him to submit the claim in format with discharge summary and investigation reports .It is also both sides admitted fact is that the insured died at Down Town Hospital on 13.11.06 and (Ext.4) is the death certificate and that Opp.Party No.4 also vide his letter dated 7.12.2006 asked him to submit requisite documents within 15 days ; and Opp.Party No.1 vide letter dtd. 20.12.2006, informed his wife that the claim was rejected on the ground that the disease for which the insured was hospitalized was a pre-existing disease which was existing prior to the proposal of the policy.
5) The complainant states that the insured had been medically examined by the doctor of the opp.party at the time of proposal of the policy and the doctor found him medically fit. This version of the complainant is admitted by the opp.party side. Secondly, the opp.party side on the basis of the report their doctor had come into opinion that the insureds’ health was good and without having any disease and thereby issued the policy . So, for that reason, the opp.party cannot be allowed to say now that the insured had pre-existing diseases.
The complainant states that the insured, on 9.10.06 at 5-30 p.m., suddenly felt chest-pain and breathing problem, for which he was hospitalized and diagnosed of having suffering from inter-cerebral Parital Hemorrhage Diabetes Mellitus with Nephropathy of recent origin.
We have perused the discharge summary (Ex.6) issued by Down-Town Hospital and it is found that the doctor certify that the insured, Late Dr. Jiten Kr.Gogoi had no any past history of breathing difficulty, coronary artery disease hypertension and diabetes mellitus, but he suddenly felt breathing problem on 9.10.06 from 5-30 p.m. and accordingly he was provided all requisite treatments by a group of doctors , but he died on 13.11.06 due to intracerebral perital haemorrhage diabetes Mellitus (recently diagnosed) with Nephropathy, coronary artery disease with thrombosis and hypoxic encephalopathy of recent origin, and he was treated at Down- Town Hospital , but he died on 13.11.2006. So, it is clear that the diseases, for which, the insured died were not pre-existing disease, but these diseases developed only on 9.10.16.Thus, it clear established that the insured Late Dr.Jitin Gogoi had no pre-existing disease at the time of issuance of the policy.
6) Both sides admit that the insured was in hospitalized state from 9.10.06 to 13.11.06 i.e. for 36 days in total. Both sides are also found admitted that the policy held by the insured is a hospitalization policy i.e. payment of Rs.1500/- per day during hospitalization period. Therefore, it was found that the insured was entitled to get hospitalization relief for 36 days from the opp.party at the rate of Rs.1500/- per day which is Rs.54,000/-
7) Both sides are found to have admitted that the nominee of the policy of the insured is his wife Sabita Gogoi and she has also died after the death of the insured and their daughter Mrs.Geetanjali Hatibaruah the complainant is the only heir of both of them. It is found that the said Geetanjali Hatibaruah filed the present complaint and therefore, she is entitled to get the amount under the said policy to which his father ( the insured) was entitled.
8) It is already found that the insured had no pre-existing disease at the time of opening of the policy and he died on 13.11.2006 due to diseases originated from 9.10.06 only. Therefore, the ground of repudiation of the claim of the complainant’s father which was done by the opp.party vide their letter dtd. 20.12.06 (Ext.7) are not justified grounds. Therefore, we hold that the very rejection of the claim filed by the father and the mother of the complainant as done by the opp.parties is a clear case of deficiency of service to the complainant side. Hence, the opp.parties are liable to pay the due amount which is Rs. 54,000/- to the present complainant as per terms and condition of the policy along with interest at the rate of 12% per annum from 20.12.2006 (the date of issue of repudiation order).
Secondly, the opp.party is also liable to pay an amount of Rs.30,000/- as compensation for causing mental agony and harassment to her late parents and herself by illegally rejecting the claim filed by her mother and also to pay atleast Rs.10,000/- as cost of the proceeding.
9) Because of what has been discussed as above, the complaint against all the opp.parties is allowed on contest and the opp.parties are directed to pay the complainant Rs.54,000/- as hospitalization cost of her father as per terms and condition of the insurance policy that had been done with them by her father late Dr.Jiten Gogoi ( Policy No. CE/00027253000100) along with interest at the rate of 12% p.a. from 20.12.2006 till full payment, and also to pay Rs.30,000/-as compensation for causing harassment and mental agony to her and her parents, and also to pay him Rs.10,000/- as cost of proceeding, to which all the opp.parties are jointly and severally liable. They are directed to pay the awarded amounts within two months , in default, the compensation and cost of proceeding part shall also carry interest at the rate of 12% per annum.
Given under our hand and seal of the District Forum, on this the 14th day of Feb, 2017.
(Md.S.Hussain)
President
(Mrs. Archana Deka Lahkar)
Member
