FINAL ORDER/JUDGEMENT

SHRI ASHOKE KUMAR GANGULY, MEMBER

This is an application u/s.12 of the C.P. Act, 1986.

The complainant was having a Health Insurance Policy bearing no. 4851884 with the OP 1 . The Sum Assured of the said policy was Rs. 1,00,000/- . Premium amount was Rs.5,900/- . Before issuance the policy, doctor from the OP examined the complainant and thereafter the OP issued the policy. The proposal form was filled up by  the men of the OP 1. The complainant went to the Tata Memorial Hospital for Health Check Up and underwent necessary check up and incurred an expenses of Rs.1,45,246/-  and made a claim to the OP with all documents  for reimbursement . The OP repudiated the claim on the ground of pre existing disease. The complainant wrote letter dated 14.09.2018 denying the allegation that it was pre existing disease. The OP did not reimburse him the amount and hence the case.

The contesting OP 1 filed their WV contending inter alia that the complaint petition is baseless and devoid of merit. In support of their contention they have submitted as follows. The complainant was a subscriber of the Group Health Insurance Policy with the OP 1 being no. 0000000004851884 for a period from 16.08.2016 to 15.08.2016 having sum assured of Rs.1,00,000/- . As per advice of a local doctor the complainant went to Tata Memorial Hospital for necessary health check up. After necessary check up the complainant was diagnosed of having the disease ‘Carcinoma Prostate.’  As per documents the complainant was admitted in the hospital on 06.04.2017 & the policy inception date was 16.08.2016. As per self declaration of the complainant he had urinary complain since April 2016 which is pre existing in nature and the current ailment is the complication of the same. As per term and conditions of the policy the expenses arising out of the above ailment is not payable as pre existing ailment is not covered under the policy exclusion clause and the benefits are not payable until 48 consecutive months have elapsed after the date of inception of the first policy with the insurer. In view of the above the OP 1 has repudiated the claim of the complainant vide letter dated 30.06.2018

 Points for Determination

In the light of the above pleadings, the following  points necessarily have come up for determination.

1)  Whether the OPs are deficient in rendering proper service to the Complainant?
            2)  Whether the OPs have  indulged in unfair trade practice?

           3)  Whether the complainant is entitled to get relief or reliefs as prayed for?

Decision with Reasons

Point Nos. 1 to 3 :-

The above mentioned points are taken up together for the sake of convenience and brevity in discussion.

            We have travelled over the documents placed on record. The complainant & the OP 1 have filed their respective Evidence supported by affidavit. They have also filed replies to the questionnaire set forth by their adversaries. They have also submitted  their BNAs.

It is admitted fact that the complainant was covered under a Group Health Insurance Policy with the OP 1 for the period from 16.08.2016 to 15.08.2017. The sum assured under the said policy was Rs.1,00,000/-.  Copy of the policy document corroborates the said fact. On perusal  of the copy policy it is observed that under the Personal Health Details( As declared by Insured in Proposal Form) of the policy it is established that the insured complainant Sankari Mohan Neogy had no Pre Existing Ailment / Disease. This is in fact a clear declaration / admission on the part of the OP 1. As per the certificate of the Hospital Tata Memorial Centre dated 07.03.2018 the complainant underwent Radiotherapy from 04.04.2017 to 16.05.2017. The expenses incurred for the treatment was Rs.1,45,246/-. We have travelled over the documents placed by the OP 1 namely Written Version, Evidence on affidavit, Brief Notes of arguments and even in reply of the OPs against the questionnaire filed by the complainant we have observed the wordings as follows

“ As per the self declaration of the insured he had urinary complain since April 2016 which is pre existing in nature and the current ailment is th

e complication of the same. But to our surprise we do not find  the said document since the same has not been filed by the OP.. More over as stated above the policy bond issued by the OP 1 is absolutely clean and clear. There is no mention of any such disease in the policy document itself which is the basic document of the contract in between the parties. As such the plea taken by the OP 1 is self contradictory. While perusing the Questionnaire of the  OP 1 under Question No. 4 the question was

“ Mr.Witness, can you deny the fact that you had urinary complain since April 2016 i.e. prior to the issuance of the policy by SBI GIC Ltd. ? “

The answer of the complainant  is “ NO”.   So the very plea taken by the OP 1 in respect of Pre Existing Disease does not stand.  The treatment taken by the complainant is very much within the period when the impugned policy is in force. The expenses incurred by the complainant as per bill of the Hospital is Rs.1,45,246/- . The sum assured of the Policy is Rs. 1,00,000/-  So the OP 1 cannot be escaped from the payment of Rs.1,00,000/- to the complainant.

In this context Ld. Advocate for the complainant cited the relevant judgement of the Hon’ble NCDRC in the matter of United India Insurance Co. Ltd. vs. Anumolu Rama Krishan reported in III(2012)CPJ 44(NC) where it is clearly mentioned that “ a person suffering from “silent diseases” may not even be aware until condition aggravates and overt symptoms appear. Repudiation not justified.”

            The Ld. Advocate for the complainant has also cited another case law reported in volume IV (2008) CPJ 511 of Hon’ble Delhi SCDRC, in the matter of Oriental Insurance Co. Ltd. and Anr Vrs. Mohinder Singh where it has categorically been mentioned  that “unless a person hospitalized/undergoes operation in near proximity of obtaining policy, he is not supposed to disclose normal wear and tear of human life.” It has also been mentioned in the said judgment vide para 7. that “Disease means a serious derangement of health or chronic deep seated disease frequently one that is ultimately fatal for which an insured must have been hospitalized or operated upon in the near proximity of obtaining the mediclaim policy.”

“ Such a disease should not only be existing at the time of taking the policy but also should have existed in the near proximity. If the insured had been hospitalized or operated upon for the said disease in the near past, say, six months or a year he is supposed to disclose the said fact to rule out the failure of his claim on the ground of concealment of information as to pre existing disease.

The above judgements are very much directional and restrains the OPs not to repudiate the genuine claims by invoking the exclusion clause or non disclosure of pre existing disease.

In the light  of the above observation, we are of the considered view that the complainants have established the case against the OP 1. OP 2, the TPA being the processing authority has no liability since they do not issue policies

All the points under determination are answered accordingly.

In the result, the Consumer Complaint  succeeds .

Hence,

Ordered

That the complaint case be and the same is allowed on contest against the OP 1 with the following directions:-

1. The OP-1 is directed to pay Rs.1,00,000/-  to the complainants  with simple interest  at the rate of 4 percentfrom 30.06.2018 till the date of payment.

2. The OP-1 is also directed to pay Rs. 10,000/- to the complainants as litigation charges.

The above order is to be complied with within a period of 30 days from the date of the order in default the complainants will be at liberty to put the order into execution.