C.F. CASE No. : CC/10/103
COMPLAINANT : Bimal Banik
S/o Late Laxman Chandra Banik
C/o Asha Cycle Stores,
Bowbazar, P.O. & P.S. Nabadwip
Dist. Nadia
OPPOSITE PARTIES/OPs: 1) Sr. Branch Manager,
LIC of India, Mahanam Math,
Poramatala Road,
Nabadwip Branch, P.O. & P.S. Nabadwip
Dist. Nadia
2) The Sr. Divisional Manager,
Life Insurance Corp. of India
Kolkata, Suburban Divisional Office, Jeevan Prabha,
1/DD-5, Sector-1, Kolkata 700064, Salt Lake City.
3) Sharmistha Banerjee,
Medicare TPA Service (I) Pvt. Ltd.
6, Bishop Lefroy Road, Kolkata - 700020
PRESENT : SHRI KANAILAL CHAKRABORTY PRESIDENT
: SHRI SHYAMLAL SUKUL MEMBER
DATE OF DELIVERY
OF JUDGMENT : 23rd September, 2011
: J U D G M E N T :
In brief, the case of the complainant is that he purchased one LICI Health Plus Plan Policy from the OP No. 1 on 18.06.08 and the policy is valid up to 31.03.07. It is his specific case that on 11.01.10 the complainant was admitted to Rubi General Hospital due to his sudden chest pain and at that Hospital he spent Rs. 2,62,944/- for his treatment. Thereafter, on 29.03.10 he submitted his claim No. 0214381 before the OP No. 1 for the above said amount. As per the queries the OP No. 3 under his letter dtd. 24.03.10 he also submitted his hospitalization claim papers before the TPA, i.e., OP No. 3. From a letter issued by the OP No. 3 dtd. 15.06.10 the complainant came to know that the OP No. 3 was unable to pay the claim amount by showing the reason, “After thought and change of records after finalization of claim.” He also submits that no question of after thought does arise in this case. In the case history form filled up by Rubi General Hospital Ltd. authority states that duration of hypertension is one year. Besides this, Dr. Sanjay Singh, Consultant Cardiac Surgeon of the Hospital who treated the complainant also issued one certificate to the effect that the complainant Mr. Bimal Banik was under his care since last year and he had no history of hypertension beyond one year. Thereafter, this complainant sent a lawyer’s notice to the OP No. 2 and 3 on 06.07.10 directing them to pay the claim amount, but to no effect. So having no other alternative he has filed the case praying for the reliefs as stated in the petition of complaint.
OP No. 1 & 2 have contested this case by filing a written version, inter alia, stating that the petition of complaint is not maintainable in its present form and manner. It is the case of the complainant that he took one Health Plus Policy of LICI and the date of commencement was on 31.03.08. This complainant submitted one claim form on 29.01.10 preferring a claim of Rs. 2,62,944/- for the alleged treatment of acute anterior septal myocardial infarction and the said claim was sent to TPA for consideration as per rules. In course of verification by the TPA it is revealed from the case history form issued by Rubi General Hospital under proper seal and signature of the Hospital that the complainant was suffering form hypertension since last five years which is a prior disease to the commencement of the said health plus policy taken by the complainant. As per policy condition, as the complainant patient was suffering from pre-existing illness, so the TPA rightly rejected the claim and intimation was given to the complainant regarding rejection of his claim. Thereafter, on 10.06.10 the complainant submitted photocopy of the case history form allegedly issued by Rubi General Hospital which was without any seal and signature by the Hospital authority, where the duration of the hypertension was written one year which was contradictory with the document submitted by the complainant earlier along with the claim form. It is clear in the subsequent document that the duration of hypertension abruptly changed from five years to one year. To verify the genuineness of the subsequent document the TPA sent the matter to the Hospital authority who informed that the duration of the disease regarding that recorded in their official record was five years and not one year. So on the basis of the inquiry from TPA, the claim was rejected and so these OPs have no liability to pay the claim amount. Hence, the case is liable to be dismissed against the OPs.
POINTS FOR DECISION
Point No.1: Has the complainant any cause of action to file this case?
Point No.2: Is the case maintainable in its present form and nature.
Point No. 3: Is the complainant entitled to get the reliefs as prayed for?
DECISION WITH REASONS
All the points are taken up together for discussion as they are interrelated and for the sake of convenience.
On a careful perusal of the petition of complaint along with the annexed documents filed by the complainant and the written version filed by the OPs it is available on record that admittedly this complainant purchased one LICI Health Plus Plan policy being No. 426654946 from the OP No. 1 on 18.06.08 which is valid up to 31.03.27. It is the contention of the complainant that on 11.01.10 he was admitted to Rubi General Hospital due to his sudden chest pain and he was treated at that Hospital where he spent Rs. 2,62,944/-. Thereafter, he submitted his claim application along with the documents before the OPs. The OP No. 3 by a letter dtd. 15.06.10 repudiated his claim with the reason “After thought and change of records after finalization of claim.” The contention of the OPs is that in the original case history of treatment submitted along the claim form it was shown that the complainant was suffering from hypertension for five years which means that prior to issuance of the policy he was a patient of hypertension, but the matter was suppressed at the time of purchasing the policy. As per the LICI rules as the complainant suffered from previous ailment so his claim was repudiated by the TPA i.e., the OP No. 3. In support of their contention OPs have filed the case history form regarding the treatment of the complainant issued by Rubi General Hospital which shows that the complainant had hypertension for five years. Regarding this it is their submission that on enquiry from TPA, regarding documentary evidence on the basis of which the claim was rejected, TPA faxed them the paper. TPA sent them fax of the Hospital authority which was submitted at the time of lodgment of claim. Fax copy of the same shows that the duration of the treatment was five years and not one year. In support of their contention no such fax copy issued by Rubi General Hospital is filed before this Forum by the OPs. On the other hand, the complainant has filed the xerox copy of case history form issued by Rubi General Hospital which shows that the complainant was suffering from hypertension for one year only. Both the case history papers are written by the selfsame person. From the complainant’s case history record filed by both the parties, it is available that Dr. Sanjay Singh and Dr. R. Sribastava treated the complainant patient at Rubi General Hospital. Dr. Sanjay Singh issued a certificate in favour of the complainant, inter alia, stating that “Mr. Bimal Banik is my patient and has been under my care since last 1 year. He has no history of hypertension beyond one year and he was not on any blood pressure controlling medications as per my knowledge.” That Sanjay Singh is the PW2 in this case. In his evidence with affidavit he has stated that Bimal Banik is his patient and he is in his care since 10.01.10 and Sri Banik has no history of hypertension beyond one year and he was not on any blood pressure controlling medications as per his knowledge. To that effect he issued one certificate on 30.06.10 in his own handwriting. In reply of interrogatories this PW-2, Dr. Sanjay Singh has stated that the case history form of Mr. Bimal Banik issued by Rubi General Hospital was written by other person but not by him. He himself treated Mr. Banik on 30.06.09 and issued one certificate to that effect that he has no history of hypertension beyond one year and he was not on any blood pressure controlling medications as per his knowledge. From the argument advanced by the ld. lawyer for the OPs it is available that in the proposal form of the health plus policy the complainant did not express anything about his previous ailment. In reply to interrogatories the OP No. 1, Sri Kousik Kumar Neogi has stated that Dr. Swapan Kumar Bhowmick as Medical Examiner examined the said Bimal Kumar Banik on 29.03.08 and at that time of examination there no discrepancy was found. Regarding this ld. lawyer for the OPs submitted that this doctor opined that he had no hypertension at the time of purchasing the policy. That report of the doctor would be controverted. In this connection he cited a ruling from AIR 1986 Kerala page 201. Perused the above cited ruling of the Hon’ble Court. At the same time, Ld. lawyer for the complainant has cited another ruling from III (2011) CPJ, page 301 Jammu & Kashmir where the Hon’ble State Commission decided, “Consumer Protection Act 1986 – Sections 2(g), 10 – Insurance (life) – Suppression of material facts – Claim repudiated – Contentions, complainant suppressed material fact with regard to ailments of diabetes and hypertension – Not accepted – OPs failed to prove allegation of suppression of material facts which had a bearing for the issuance of policy – OPs to indemnify complainant by making payment of rupees 10 lac along with the interest @ 8% and cost of litigation.”
On a careful perusal of both the rulings, we hold that this ruling is applicable in the instant case as the OPs have not filed any document to establish that the complainant had hypertension prior to purchase of the health plus policy from the OP No. 1. On the other hand, from the document filed by the complainant specially the certificate issued by Dr. Sanjay Singh we hold that the complainant was suffering from hypertension for one year prior to his ailment and not for 5 years as alleged by the OPs. Regarding the amount of compensation nothing is agitated by the OPs in the written version filed by them.
Ld. lawyer for the OPs has agitated that the case is not maintainable in its present form and nature as the LIC is not made a party in this case as per LIC rules. But from the cause title of the petition of complaint, we find that LIC is duly made party in this case, who is represented by its Sr. Branch Manager and Sr. Divisional Manager. Both the Sr. Branch Manager and the Sr. Divisional Manager are made parties in this case as representatives of the LIC and not in their individual capacity. They have filed the written version on behalf of the LIC being the representative of the LIC. In the affidavit filed by the OP No. 1 it is categorically stated that the OP No. 1 being the Branch Manager of the LIC and being well conversant of the facts of this case is competent to swear this affidavit. So we have no hesitation to hold that they have contested this case by filing written version on behalf of the LICI who is the actual OP in this case as the LIC sold the health plus policy to the complainant. We do further hold that the present case is quite maintainable in its present form and nature.
In view of the above discussions, our considered view is that the complainant has become able to prove his case. So he is entitled to get the reliefs as prayed for. In result the case succeeds.
Hence,
Ordered,
That the case, CC/10/103 be and the same is decreed on contest against the OPs. The complainant is entitled to get the claim amount of Rs. 2,62,944/- plus Rs. 3,000/- for the harassment caused to him along with litigation cost of Rs. 2,000/- i.e., in total Rs. 2,67,944/-. The OPs are jointly and severally liable to pay the decretal amount to the complainant within a period of one month since this date of passing this judgment, in default, the decretal amount will carry interest @10% per annum since this date till the date of realization of the full amount.
Let a copy of this judgment be delivered to the parties free of cost.
