For the Complainant -Sri Prasanta Banerjee, Advocate
For the OP 1 - Smt. Debjani Banerjee, Advocate
For the OP 2 - Sri Amitava Chowdhury, Advocate
FINAL ORDER/JUDGEMENT
SHRI ASHOKE KUMAR GANGULY, MEMBER
This is an application u/s.12 of the C.P. Act, 1986.
The fact of the case in brief is that the Complainant Mrs. Uma Dhar took out a Group Health Insurance Policybearing No.0000000001763394 from SBI General Insurance Company on 25.04.2014 on the life of self&spouse for Sum Assured of Rs.1,00,000/-(Rupees One Lakh) only for the policy year from25.04.2014 to 24.04.2015.The policy was renewed on 29.04.2015 for the next policy year from 25.04.2015 to 24.04.2016 for sum assured of Rs. 10,00,000/- . The policy was further renewed on 25.04.2016 for the policy year from 25.04.2016 to 24.04.2017 for sum assured of Rs.5,00,000/-. The Complainant took admission on 22.02.2017 at the hospital Nightingale Diagnostic & Medicare Centre Pvt. Ltd. for treatment of Gross Osteoarthritis & underwent Knee Surgery over there. The total bill for the treatment was Rs.3,26,434/- out of which the OP 1 reimbursed the cashless benefit of Rs. 1,00,000/- . The balance amount was repudiated on the ground of pre-existing disease. The instant case has been filed against the said repudiation.
The OP 1 has contested the case by filing Written Version contending inter alia that the repudiation action on the part of OP 1 is justified on the ground of suppression of pre-existing disease & the case is not maintainable either in law or in facts & liable to be dismissed with cost. The OP 2 has not contested the case& the case has run ex parte against them.
On the pleading of the parties the following points have necessarily come up for determination.
- Whether there is any deficiency of service on the part of the OP 1.
- Whether there is any indulgences of unfair trade practice on the part of OP 1
- Whether the Complainant is entitled to the reliefs as prayed for.
Decision with Reasons
Point Nos. 1 to3 :-
All the points are taken up together for the sake of convenience and brevity in discussion.
Both parties have tendered their Evidence on Affidavit, Reply to the questionnaire set forth by their adversaries, they have also filed their respective BNAs. We have travelled over all the documents placed on record.
Facts remain that the Complainant had a Group Health Insurance Policy bearing No.0000000001763394 with the SBI General Insurance Company Ltd. being theOP 1 for a Sum assured of Rs.5,00,000/- valid for the period from 25.04.2016 to 24.04.2017. The Policy was originally taken out on 25.4.2014. The Complainantgot admitted in the hospital Nightingale Diagnostic & Medicare Centre Pvt. Ltd. on 22.02.2017 for some health problem& treated there within the valid period of Insurance. Thereafter she submitted claim for reimbursement of Rs.3,26,434/- to the OP 1 which was repudiated in part by the OP 1 vide their letter dated 29.05.2017.
There is no dispute in between the parties up to this stage .As such deficiency of service on the part of OP 1 is not found observed.
Now the main issue of the complaint petition is rejection of claim amount of Rs.2,26,434/- being the balance amount of treatment against the maximum coverage of Rs.5,00,000/- in the said Health Insurance Policy. As per W/V &Evidence on Affidavit of the OP the Complainant did not disclose the pre-existing disease “Osteoarthritis” at the time of renewal on 25.04.2016 enhancing the sum assured to Rs.5,00,000/- for which as per EXCLUSION CLAUSE of the Policy the balance amount is not payable .
Now let us see the Exclusion Clause .The same is reproducedherein belowfrom the Terms & Conditions of the Policy.
EXCLUSION
We will not pay for any expenses incurred by the insured person in respect of claims arising out of or howsoever related to any of the following and for any of the cover ages offered under the policy including add on covers :
- Pre-existing Diseases Extension :
2. Benefits will not be available for any condition, ailment or injury or related conditions for which Insured has been diagnosed,received medical treatment, had sighs and / or symptoms, prior to inception of Insured Person’s first group health Policy, until 48 consecutive months have elapsed, after the date of inception of the first group health Policy with Insurer.
This Exclusion shall cease to apply if Insured Person has maintained this Health Insurance Policy with Insurer for a continuous period of a full 4 years, without break from the date of Insured’s first group Health Insurance Policy with Insurer.
This Exclusion shall also applyto the extent of the amount by which the limit of Indemnity has been increased if the Policy is a renewal of the Health Insurance Policy with Insurer without break in cover. This exclusion shall also apply to any additional health Policy that the Insured has purchased from us.
Keeping in view of the above exclusion clause the OP 1 has relied upon a Xerox copy of the Prescription of Dr. Indrajit Sarkar of Nightingale Hospital dated 25.02.2015 issued to the Complainant where there are some advices to be followed by the Complainant Patient Smt. Uma Dhar.
But the OP 1 has failed to understand that a mere Prescription does not necessarily establish the onset of the disease. They have failed to produce any concreteclinical evidence where from the onset of the said disease could be proved.
So, the self-madeinterpretation of the OP-1 in respect of pre-existing disease of the Complainant resulting in repudiation of claim without producing proper evidence tantamountto unfair trade practice. Accordingly the Complainant is entitled to get the relief in part as prayed for. Thus all the points are answered in the affirmative.
In the result the complaint succeeds in part.
Hence
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That the Complaint Case be and the same is allowed on contest in part against the OP 1 and ex parte against OP 2 with the following directions.
1. The OP 1 is directed to reimburse Rs. 2,26,434/-to the complainant against her total hospital expenses.
2. The OP 1 is further directed to pay Rs. 25,000/- to the Complainant for harassment & mental agony along with Rs.10,000/- as litigation cost.
3. The OP 1 is directed to comply the above orders within 45 days from the date of the order failing which the Complainant is at liberty to put the order in execution according to law.
