Order-14.

Date-27/05/2015.

Complainant Smt. Mahuya Mazumder by filing this complaint has submitted that complainant is a Mediclaim Policy Holder vide Policy No. 101500/48/13/8500000479 for the period from 23.04.2013 to midnight of 22.04.2014 for the benefit of sum assured of Rs. 2,50,000/-.  During valid period of the said Mediclaim Policy, complainant fell on wet floor in the bathroom on 16.05.2013 being slipped which is accidental in nature and was admitted at Microlap Nursing Home due to traumatic Subarachanoid Hemorrhage under treatment of a Neurologist and also a Neurosurgeon Dr. Abhijit Chatterjee and after treatment she was discharged from the said Nursing Home on 31.05.2013 and thereafter complainant submitted claim along with all materials and Mediclaim Papers for settlement of the claim.  But after nine months on 28.03.2014, complainant got a regret letter from the op with a false and fabricated note that “As per RMO’s note on admission, it was a fall in Bathroom while patient slipped on wet floor but as per ICP dated 18.05.2013 the fall occurred after taking overdose (6 tablets) of analgesics and analgesics were taken before the incident occurred”.

          On receipt of the same, complainant was completely astonished for making a fabricated story regarding accident and rejection of the claim without any valid reason.  Though complainant spent Rs. 1,27,000/- for her treatment as she was hospitalized being injured after her fall on the bathroom.  Subsequently complainant sent a demand notice to the ops on 30.04.2014 through Registered Post with A/D and it was duly delivered.  But op did not pay any heed and did not consider the claim for which for negligent and deficient manner of service this complaint is filed for redressal.

          On the other hand op by filing written statement submitted that insured Mahuya Mazumder is no doubt a Mediclaim Policy Holder and preferred a claim for Rs. 1,31,975/- for her admission on 16.05.2013 to 31.05.2013 in Microlap Nursing Home for treatment of Traumatic Subarachnoid Haemorrhage to Lowing Head Injury. 

          But after considering the Mediclaim Documents, it was found that she had a history of HTN and IHD with PTCA done and the hospitalization is for HTN indeed Subrachnoid Hemorrhage and that the disease is pre-existing in first year of policy coverage, so the claim is repudiated under clause 4.1 of standard individual policy and that matter was also reviewed and it was also observed that insured had been suffering from HTN and diabetes but ICP copy dated 17.05.2013 shows that the patient Mahuya Mazumder, the insured suffered from HTN and a known case of IHD with PCTA done and old ischaemic CVA and as per RMO’s note of admission, it was a fall in bathroom while patient slipped on wet floor but as per ICP dated 18.05.2013, the fall occurred after taking overdose (6 tablets) of analgesic and analgesics were taken before the incident occurred.

          So as per policy condition, it was repudiated and there was no negligence and deficiency on the part of the op when the policy document being a contract and it has to be read strictly and binding upon both the parties.

          In the above circumstances, op prayed for dismissal of this case.

                                                       Decision with reasons

          On proper consideration of the complaint and written version and also considering the argument as advanced by the Ld. Lawyers of both the parties and also considering the discharge summary, it is found that she was admitted to Microlap Nursing Home with a history of head injury after accidental fall in the bathroom and was treated in the hospital for the period from 06.05.2013 to 31.05.2013. 

          But from the discharge summary, there is no such proof that she had her any pre-existing disease.  From the treatment sheet also we do not find any such materials that she had her past history of pre-existing disease.  For the sake of the argument if it is accepted that there was some hypertension, but it is negligible in nature in view of the fact that report shows that blood pressure was not very high.  But it has become a practice of the Insurance Company not to allow any claim.  When it is found that there is any sort of blood pressure forthwith they rejects it and practically all the insurance companies already decided that they shall not have to dispose of the Mediclaim policies but shall have to reject it by showing blood pressure or sugar.  But blood pressure and sugar are not vital disease for causing any death.  When precautionary measures and medicines are there and all over the world, blood pressure and sugar have become a part of a body system after certain age and it is not a pre-existing disease.  But the progmatic attitude of the Insurance Company is always found when claim is repudiated on the ground of blood pressure and sugar.  But this orthodox view of the Insurance company should be thrown away in view of the present worldwide Medical Authorities’ opinion that blood pressure and sugar even if it is found that high, it is not any disease unless and until it goes beyond any control where medicine cannot control it.

          Considering all the above fact and materials, we are convinced to hold that repudiation as made by the ops is completely biased in nature and it has become their practice.  So, we are not confirming their decision for repudiation which is found without any medical foundation and moreover ops have their orthodox view regarding blood pressure and sugar and this orthodox is not confirmed by world famous doctors who have already confirmed that blood pressure and sugar which can be controlled by medicine so cannot be a disease if it does not go beyond control but same can cause damage of the entire body system when it is a disease when same are not controllable.

          Fact remains that if it is found that a person suffering from any disease again and again, then it shall be treated as pre-existing disease and such sort of clue of the Insurance Company is not only unscientific but also arbitrary in nature and that arbitrary attitude has been applied in this case for which we are convinced that repudiation of the claim of the complainant was not legal and justified.  But anyhow we have gathered that complainant has tried to convince that he spent Rs. 1,31,000/- and odd.  But considering the attitude of the ops and also the materials on record, we find that as per clause, complainant is entitled to Rs. 80,000/- and op is bound to release that amount at once and to pay it.

          In the result, this complaint succeeds.

          Hence, it is

                                                             ORDERED

          That the complaint be and the same is allowed on contest against the op nos. 1 & 2 with cost of Rs. 2,000/- and same is dismissed against op no.3 in exparte form without any cost.

          Op nos. 1 & 2 jointly and severally are hereby directed to pay a sum of Rs. 80,000/- to the complainant within one month from the date of this order positively, treating the entire claim of the complainant as finally settled when the repudiation is unjustified and arbitrary in nature.

          If ops fail to comply the order of this Forum and fail to satisfy the decree within one month from the date of this order, op shall have to pay peal damages  at the rate Rs. 200/- per day till full satisfaction of the decretal amount and if it is collected it shall be deposited in the Forum even if it found that complainant is reluctant to comply the order, in that case penal action shall be started against the ops u/s 27 of C.P. Act 1984 for which further penalty and fine shall be imposed.