Order No. 13 dt. 28/08/2017
The case of the complainant in brief is that the complainant was suffering from cough and fever in the month of July 2014 and after blood test it was revealed that she was suffering from paratyphoid fever. After treatment by providing antibiotic to him there was no remission. Therefore the complainant made several tests at AMRI Hospital as well as USG. Because of the illness of the complainant he was treated at AMRI Hospital and after treatment the complainant made a claim of Rs.70,000/- from o.ps. but the same was repudiated on the ground that the complainant suppressed the material fact of his prior illness, therefore as per clause 7 of the policy condition the complainant was not entitled to get any claim made by him. On the basis of the said fact the complainant filed this case praying for direction upon the o.ps. for payment of the amount of Rs.70,000/- as well as compensation of Rs.50,000/- and litigation cost of Rs.20,000/-.
The o.ps. contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that the complainant had taken a Senior Citizen Redcarpet Insurance Policy through online covering for the sum insured of Rs.2 lakhs for the period from 21.2.14 to 20.2.15 and the policy was issued accordingly. In the said policy it as clearly stated that that the insurance under the policy is subject to conditions, clauses, warranties, exclusions, etc. attached and accordingly a contract of insurance was entered into between the complainant and o.ps. As per exclusion clause no.5, 50% of each and every claim arising out of all disclosed pre-existing diseases and 30% in case of all other claims which shall be borne by the policy holders / insured. From the medical papers filed by the complainant and on perusal and examination of those papers it was found that the complainant seeking reimbursement of hospitalization expenses for treatment of enteric fever, serocis of lever CRF at AMRI Hospital, Kolkata wherein it was observed that : (1) As per the discharge summary of AMRI Hospital, Salt Lake dt.7.8.14 the insured patient had a past history of HAV infection 7 years ago, (2) USG whole abdomen report dt.31.7.14 shows heterogeneous parenchymal echo texture, altered globulin ratio, etc. which indicates that the present ailment is long standing and it cannot occur within a short period.
At the time of inception of 1st policy which was from 3.1.12 the insured did not disclose the above mentioned medical history in the proposal form which amounts to misrepresentation and concealment of material fact.
As per condition 7 of the policy if there is any misrepresentation / non disclosure of material fact whether by the insured person or any other person acting on his behalf the company is not liable to make any payment in respect of any claim. Considering the above facts the claim of the complainant was repudiated by a letter dt.13.10.14 and the same was communicated to the insured. On the basis of the said fact o.ps. denied that there is any deficiency in service or any unfair trade practice on the part of o.ps. and thereby the case is to be dismissed.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant had the policy with o.ps.?
- Whether the complainant suffered illness and he submitted medical bills for reimbursement?
- Whether there was any suppression of material fact by the complainant at the time of obtaining policy?
- Whether there was any deficiency in service on the part of o.ps.?
- Whether the complainant will be entitled to get the relief as prayed for?
Decision with reasons:
All the points are taken up together for the sake of brevity and avoidance of repetition of facts.
The complainant himself argued the case and he stated that he being a doctor and attached to West Bengal Health Service. The complainant all on a sudden noticed that he was suffering from cold and cough for which he made several tests but no improvement was noticed, thereafter he went to AMRI Hospital and several tests were made and after his admission in the said hospital and discharged from same he submitted a medical bill of Rs.70,000/- which was repudiated by o.ps. Accordingly, the complainant stated that the repudiation made by o.ps. was done in arbitrary manner and for which the complainant filed this case praying for direction upon the o.ps. for reimbursement of the medical bill as well as compensation.
Ld. lawyer for the o.ps. argued that the complainant had the insurance policy at the relevant point of time. The complainant after recovery from his alleged illness submitted a medical bill amounting to Rs.70,000/-. After going through the documents filed by the complainant as well as discharge summary from the hospital it’s established the fact that the complainant suppressed the material fact of his existing disease and by suppressing the said fact he obtained the policy and thereby as per the terms and conditions of the policy, particularly clause 7 of the policy condition the complainant of the complainant was repudiated. There was no deficiency in service on the part of o.ps. and thereby the case is to be dismissed.
Considering the submissions of the respective parties it is an admitted fact that the complainant had the policy at the relevant point of time and it is also an admitted fact that the complainant had some problems for which he underwent some medical tests. It is also found from the complaint itself that the complainant underwent several tests but he did not get any relief in spite of taking antibiotic and other medicines. Thereafter the complainant admitted to AMRI Hospital wherefrom it is evident that the complainant got the relief and after his discharge from the said hospital he submitted the medical bill of Rs.70,000/-. The bone of contention between the parties in this case is that whether the complainant suppressed the material fact of his illness prior to the obtaining policy from o.ps. It appears from the documents filed by the complainant himself that he was suffering from various ailments and from the hospital discharge summary it appears that he was treated outside with azithral / ceftum / zanocin / cefixime / that no improvement and investigation showed the creatinine and dyselectrolytaemia and raised FBS. His USG suggested CLD with PHT splenomegaly and minimal ascites with B/L renal parenchymal disease, HAV infection 7 years ago. On the basis of the said fact the claim of the complainant was repudiated. On perusal of the record we find that from the documents filed by the complainant it appears that he had an attack of Hepatitis A 7 years back. Hepatitis A is a common disorder and there was spontaneous recovery without any complication and the complainant did not suffered from any disorder in lever after recovering from HAV. In view of such facts and circumstances of the case, we hold that the claim made by the complainant for suffering the illness 7 years ago from the date of opening of the policy cannot be a ground for repudiation of the claim of the complainant, particularly when the complainant disclosed everything at the time of obtaining the policy. Therefore, we hold that the claim made by the complainant was repudiated by the insurance company without any cogent reason whatsoever. Accordingly, we hold that there was deficiency in service on the part of o.ps. and accordingly the complainant will be entitled to get the relief as prayed for. Thus all the points are disposed of accordingly.
Hence, ordered,
That the CC No.32/2015 is allowed on contest with cost against the o.ps. The o.ps. are jointly and/or severally directed to pay an amount of Rs.70,000/- (Rupees seventy thousand) only to the complainant towards the medical bill along with compensation of Rs.10,000/- (Rupees ten thousand) only for harassment and mental agony and litigation cost of Rs.5000/- (Rupees five thousand) only within 30 days from the date of communication of this order, i.d. an interest @ 10% p.a. shall accrue over the entire sum due to the credit of the complainant till full realization.
Supply certified copy of this order to the parties free of cost.
