Date of filing: 08.08.2018
Judgment date: 20.12.2022
Mrs. Sashi Kala Basu, Hon’ble President
This complaint is filed by the complainant Shri Swaran Sen U/s. 12 of the Consumer Protection Act, 1986, against the opposite parties (referred as O.P.s hereinafter) namely (1) SBI General Insurance Company (2) Medicare Insurance T.P.A. Services (India Pvt. Ltd.) and (3) Branch Manager, State Bank of India alleging deficiency in service and unfair trade practice on part of the opposite parties.
The case of the complaint in short is that in September, 2015 complainant as per the instruction of the then Branch Manager State Bank of India, Prince Anwar Shah Road, insured himself for medical health service including hospitalization service covering under the Policy No. 0000000003462996 dated 05/10/2015 issued by the opposite party no. 1. Premium was automatically being deducted from his savings bank account no. 31460133208. Policy was renewed and was valid till 29/11/2018. The sum insured was Rs. 1,00,000/-. Complainant was admitted at Fortis Hospital on 30/03/2018 and was discharged on 04/04/2018. Complainant claimed cashless treatment from that hospital who claimed from O.P. No. 2 but he was not provided the cashless treatment and was asked to come for reimbursement. Ultimately complainant paid sum of Rs. 83,701/- towards the medical bill and submitted all the relevant documents claiming the said sum before the O.P. No. 2. But he received a letter dated 05/06/2018 from the O.P. No. 1 stating that the Pheumothorax disease was pre existing in nature and thus the opposite party was unable to consider the reimbursement. Complainant than realized that the O.P. had issued a new policy being no. 0000000005241559 dated 04/11/2016 ignoring the original policy issued in the year 2015. So as no reimbursement was done of the amount towards his hospitalization, complainant sent a demand notice dated 18/07/2018 to the O.P.s through his Ld. Advocate but as O.P.s paid no heed, present complaint has been filed praying for directing the opposite parties to pay the claimed amount of Rs. 83,701/- with the statutory interest, to pay Rs. 2,00,000/- as compensation and Rs. 50,000/- towards the cost of litigation.
O.P. 1 is contesting the case by filing written version denying and disputing the allegation contending inter alia that the complainant on 05/10/2015 subscribed a group health insurance policy for the period from 05/10/2015 to 04/10/2016 having sum assured of Rs. 1,00,000/-. Thereafter complainant on 04/11/2016 again obtained a policy. A fresh policy having validity from 04/11/2016 to 03/11/2017 was issued as renewal grace period of 30 days was already over. The said policy issued on 04/11/2016 was again renewed on 30/11/2017 having validity period from 30/11/2017 to 29/11/2018. As per the documents submitted by the complainant (discharged certificate of R.S.V. Hospital Pvt. Ltd. dated 28/01/2016) it is observed that complainant was first admitted with left spontaneous Pheumothorax on 28/01/2016 and since the policy insertion date was 4/11/2016, considering the same, cashless facility was denied. Complainant was not entitled to the claim amount as per the terms of policy as the expenses arising out of the preexisting illness is not covered under the policy. It falls within the exclusion clause. So the opposite party no. 1 repudiated the claim of the complainant on 05/06/2016 and intimated the complainant in writing showing the reason for such repudiation. So the O.P. has prayed for dismissal of the case. Other O.P.s did not take any step and the case proceeded exparte against them.
During the course of trial, complainant and also the O.P. filed their respective affidavit in chief followed by filing of questionnaire and reply thereto and ultimately argument has been heard of both sides. B.N.A. has also been filed by both the parties.
Following points required determination:-
- Whether there has been deficiency or unfair trade practice on the part of the opposite parties?
- Whether the complainant is entitled to the relief as prayed for?
DECISION WITH REASON
Both the points being interrelated are taken up for a comprehensive discussion. In this case there is no dispute that the complainant had availed the group health insurance policy of the opposite party no. 1 for the period from 05/10/2015 and the sum assured was Rs. 1,00,000/-. However according to the complainant he was under the belief that his policy was renewed in the year 2016 but when his claim was denied, he realized that the fresh policy was issued having validity period from 04/11/2016 to 03/11/2017. There is also no disputes that the complainant was hospitalized on 30/03/2018 and was discharged on 04/04/2018 and had paid a sum of Rs. 83,701/-. The only contention raised by the opposite parties is that disease Pheumothorax was pre existing disease as the documents submitted by the complainant disclosed that the complainant was admitted at R.S.V. Hospital Pvt. Ltd. with left spontaneous Pheumothorax on 28/01/2016. Since policy inception date was 04/11/2016, as per the terms and conditions of the policy, the expenses arising out of the said ailment was not payable as it fell within the exclusion clause. So question remains to be considered by this commission is whether disease Pheumothorax was pre existing disease and whether the complainant intended to suppress the said disease? It is apparent from the admitted case of the parties that the complainant had obtained the policy on 05/10/2015. The alleged prescription of R.S.V. Hospital dated 28/01/2016 even if taken into consideration that the complainant was admitted for the said spontaneous Pheumothorax then also it is within the said coverage of policy of 2015. It is true that the complainant delayed in getting the policy of 2015 renewed for few days but it can never be said that any suppression of disease was made by the complainant. It may further be pointed out that from the said documents of R.S.V. Hospital it appears that no chest drain was done and the complainant was discharged. So even though the complainant was admitted with an observation for chest drain but ultimately it seemed that it did not required. So the contention of the O.P. that complainant was suffering from preexisting Pheumothorax and there was suppression of the ailment cannot be accepted. In such a situation complainant is entitled to refund of the claim amount of Rs. 83,701/- along with interest on the said sum (as compensation).
Hence,
ORDERED
CC/503/2018 is allowed on contest against O.P. No. 1 and exparte against O.P. No. 2 & 3. Opposite parties are directed to pay claim amount of Rs. 83,701/- along with interest on the said sum @ 8% p.a. from the date of payment of the said sum in the Fortis Hospital to till this date, within two months. In default of payment, sum shall carry further interest @8% p.a. till its realization. O.P.s are also directed to pay litigation cost of Rs. 8,000/- to the complainant within the aforesaid period of two months.
