DATE OF FILING                    :     25.04.2014.

DATE OF S/R                            :      20.06.2014.

DATE OF FINAL ORDER      :     13.01.2015.

Anil Baran Roy  Chowdhury,

Diamond  City West, 18 Hochi Minh Sarani, Tower 7,

Flat 8C, Bakultala, P.O. Sarsuna,

Kolkata 700061. ……………………………………………………….COMPLAINANT.

-          Versus   -

1.         Sr. Divisional Manager,

            The Oriental Insurance Co. Ltd.

            P-4, Dobson Lane, P.S. Golabari,

District – Howrah,

PIN -  711101.

2.         Medi Assist India Pvt. Ltd.,

            53A, Rafi Ahmed Kedwai Road,

            opposite Gulson Hotel,  P.S. Park Street,  

            Kolkata  7000 16……………………………………………OPPOSITE PARTIES.

                                                P   R    E     S    E    N     T

President     :     Shri T.K. Bhattacharya, M.A. LL.B. WBHJS.

Member       :     Smt. Jhumki Saha.

                                                 F  I   N   A    L       O   R   D    E     R

1.Complainant, Anil Baran Roy Chowdhury,  by filing a petition U/S 12 of the C .P. Act, 1986 ( as amended up to date ) has prayed for a direction to be given upon the o.ps. to pay the claim of Rs. 74,857/-,   Rs. 50,000/- as compensation for mental harassment and agony and cost of litigation of Rs. 5,000/- along  with other relief or reliefs as the  Forum may deem fit and proper. 

2.Brief fact of the case is that complainant took one medi claim policy jointly with his wife in the year 2010. O.p. no. 1, being the insurer, issued policy document. Subsequently the said policy was renewed in the years 2011, 2012 & 2013. During the policy period of 28.9.2012 to 27.9.2013, the wife of the complainant, namely Smt. Manisha  Roy Chowdhury, got admitted to hospital from 15.6.2013 to 28.6.2013 and total expenses was Rs. 46,690.50. So, the complainant submitted claim from with o.p. no. 1 through o.p. no. 2 with respect to the policy being no. 311700/48/2013/3319 on 05.7.2013 vide Annexures. But o.ps. vide their letter dated 11.11.2013 marked as ‘C’ addressed to Smt. Manisha  Roy  Chowdhury, repudiated the said claim on the ground of pre-existing disease.  Thereafter a second claim was also lodged by the complainant for the treatment of his wife on 26.11.2013 with o.p. no. 1 through o.p. no. 2 during the policy period from 22.10.2013 to 21.10.2014, having no. 311700/48/2014/4771 for a claim of Rs. 28,167 vide annexure. The second claim was also repudiated by O.Ps. on 21.02.2014 vide their letter marked as ‘D’ on the same ground of pre-existing disease as laid down in the clause 4.1 of policy terms and conditions. So being frustrated and finding no other alternative, complainant filed this instant petition with the aforesaid prayers.

3.Notices were served upon the o.ps. Only o.p. no. 1 appeared and  filed  written version. But the o.p. no. 2 remained absent and no written version was filed by them.  Accordingly, case heard on contest against o.p. no. 1 and ex parte against o.p. no. 2.

4.Upon pleadings of both parties two points arose for determination :

i)          Is there any deficiency in service on the part of the O.Ps.  ?

ii)                  Whether the complainant is  entitled to get any relief as prayed for ? 

DECISION  WITH   REASONS      :

5.Both the points are taken up together for consideration. O.P. 1 in its W/V vide paras 7 and 9 has categorically stated that complainant was suffering from history of platelet count loss for the last 20 years, multiple haemangiome for 15 years, hypertension of last 10 years  as per Dr. Rathin Ghosh’s prescription dt. 15.06.2013. And the first claim of the complainant arose due to her treatment of severe dysuria, mental confusion, extreme physical weakness which led to the diagnosis of 1) diffuse atrophy of Brain, 2) Ventricular and Atrial Arrythmia, 3) Thrombocytopenia 4) VTI 5) Rectal Prolapse, 6) Hypertension. So according   to O.P. 1, complainant was suffering since long and she suppressed all these material facts and according to 4.1 clause of the terms and conditions of the policy document, the claims could not be allowed. Here we take a pause. Complainant took the policy in the year 2010 when both the complainant and his wife were above 70 years of age. So, before taking the premium from the complainant to cover the risk of medical expenditure, it was definitely the sole duty of O.P. 1 to conduct a thorough medical check up of both of them. O.P. has relied upon the prescription dated 15.06.2013 wherefrom it is found that complainant was suffering from platelet count loss along with other diseases. And complainant submitted the first claim on 05.07.2013 annexing the copy of this prescription. Even then O.P. 1 renewed the policy and policy document being no. 311700/48/2014/4771 was issued for the period 22.10.2013 to 21.10.2014 on receipt of Rs.3,320/- as premium amount from the complainant. So it is clear that at the time of receiving the premium from the people they do not care for any disease, whatsoever. But at the time of releasing the claim amount, they are very much particular about policy terms and conditions. The organisations like O.P.1 should remember that whatever policy term and conditions be, those are not mandatory. They have framed the terms and conditions unilaterally. A person who was  above 75 years at the time of hospitalization, she is having problem of hypertension, platelet count loss etc. which is very common. The immunity level  of that person would definitely come down at this age. For that o.p. no. 1 cannot repudiate her legitimate claim. It is not only illegal but also harassing, which should not be allowed  to be perpetuated. O.p. no. 1 should remember that they are not running a business only to gain a profit. They have some kind of social obligation, which they cannot simply ignore. Moreover, the o.p. no. 2  has not cared to appear before the Forum even after receiving summons. No W/V has been filed by them which clearly shows that they have nothing to put forward in their favour. And the complaint petition remains unchallenged and uncontroverted against o.p. no. 2. And we have no difficulty to believe the unchallenged testimony of the complainant.  O.ps. have miserably failed   to keep promise which certainly amounts to deficiency in  service coupled with unfair trade practice  on their  part which should not be allowed to be perpetuated for an indefinite period. By their whimsical repudiation of the mediclaim amount, complainant and his wife have suffered from severe mental agony and pain which o.ps. failed to realize.  And we are of the candid opinion that it is a fit case where the prayers of the complainant  should be allowed. Points under consideration are accordingly decided.

      Hence,

                                    O     R     D      E      R      E        D

      That the C. C. Case No. 250 of 2014 ( HDF 250  of 2014 )  be  allowed on contest with  costs  against  the O.P. no. 1 and ex parte with costs against o.p. no. 2.   

      That the  O.Ps. are jointly and severally directed to pay Rs. 74,857/- being the total claim amount   to the complainant within one month from the date of this order.

       That they are further  directed to pay to the complainant an amount of Rs. 5,000/- as compensation and Rs. 2,000/-  as litigation costs.

      That the o.ps. are further directed to pay the entire amount of Rs. 81,587/- to the complainant  within one month from the date of this order i.d., the aforesaid  amount shall carry an interest @ 9% per annum till full realization.        

      The complainant is at liberty to put the decree into execution after expiry of the appeal period.

      Supply the copies of the order to the parties, as per rule.            

DICTATED  &    CORRECTED

BY   ME.  

      (  Jhumki Saha  )                                                                   

  Member, C.D.R.F., Howrah.