Order-14.
Date-25/01/2017.
Shri Pulak Kumar Singha, Member.
This is an application u/s.12 of the C.P. Act, 1986.
In brief the case of the complainant is that complainant first time purchased mediclaim policy on 21/01/2008 from O.P.-2 i.e. Proforma O.P. Reliance General Insurance Co. Ltd. and the said policy was renewed year after year and valid up to 21/01/2011. Thereafter the said policy was ported out under O.P.-1 i.e. Star Health & Allied Insurance Co. Ltd. and renewed for last six years period, commencing from 21/01/2011 and still continuing to 30/01/2017 without any break. On 17/08/2014 the complainant intimated to O.P.-1 that he would be admitted on 18/08/2014 in the Calcutta Medical Research Institute, Kolkata for the treatment and surgery of left upper ureteric calculus. The said intimation was registered in the office of O.P. as claim No.CLM/2015/19121/109680 with corresponding reference No. CLI/2015/191121/0109307. Accordingly the complainant admitted to the said hospital and after discharge from the said hospital complainant submitted his claim along with bills amounting to Rs.2,09,000/- to O.P.-1. But on 30/09/2014 O.P. has repudiated the claim on the ground of pre-existing illness. Complainant raised objection by sending letters on 12/07/2016 to the different offices of the O.P. with a request to pay Rs.2,09,000/-. Subsequently send legal notice by post to the said offices for getting his claim amount. But O.P.-1 did not pay heed to the claim of the complainant. Finding no other alternative the complainant filed this complaint before this Forum for getting relief.
O.P.-1 contested this case by filing W.V. denying the allegations of the complainant stating inter alia that the complainant has suppressed various material facts, the complainant is guilty of suppression and concealment of important material facts and willful misrepresentations. This O.P. on receiving the grievance of the complainant, reviewed the grievance and immediately without prejudice to his rights issued demand draft being No.948984 dated 29/08/2016 for Rs.2,02,700/- and paid to the complainant’s account on 21/09/2016. This O.P. has no deficiency in service and prayed for rejection of the complaint.
O.P.-2 also contested the case by filing their W.V. stating inter alia that the complainant made this O.P. as Proforma O.P. Complainant purchased the policy in the year 2008-2009 and subsequently renewed till 20/10/2011 of this O.P. company. This O.P. in no way liable for repudiation of claim as the claim disputed with the O.P.-1, who is the Insurer of Mediclaim Policy for the period for 2014-2015. This O.P. in no way linked with the present dispute and pray to dismiss the complaint.
Point for Decision
- Whether the O.P.-1 was negligent and deficient in providing service to the complainant ?
- Whether the complainant is entitled to get relief as prayed for ?
Decision with Reasons
All the points are taken together for the sake of convenience brevity.
On careful perusal of the complaint as well as W.Vs. together with the evidences, documents on record and consideration of the argument advanced by the Ld. Lawyers of the parties, it appears that complainant first time purchased mediclaim policy from the Proforma O.P. on 21/01/2008 which was continued up to 21/01/2011. Subsequently the complainant ported out with O.P.-1 and renewed the said policy year after year and still in continuation with a validity up to 30/01/2017. During subsistence of the said mediclaim policy the complainant admitted at the Calcutta Medical research Institute, Kolkata on 18/08/2014 with prior intimation to the O.P.-1. Getting discharged after surgery of left upper ureteric calculus from the said hospital complainant submitted his claim along with bills for total amount of Rs.2,09,000/- to O.P.-1, which was paid by the complainant to the said hospital before his discharge.
On 30/09/2014, however, the claim of the complainant was closed by O.P.-1 on the ground preexisting disease. On 16/10/2014 complainant submitted his second reminder. Subsequently on 11/07/2016 complainant sent demand letter by post to the both offices of O.P.-1. Lastly on 25/07/2016 complainant sent legal notice in respect of his claim and as per postal track report that was duly received by O.P. It appears from the W.V. filed by the O.P. that on receipt of legal notice O.P.-1 paid Rs.2,02,700/- by demand draft to the complainant’s account on 21/09/2016 but the said demand draft was drawn on 29/08/2016.
It appears from the case record that O.P. -1 stated in its W.V. that on scrutiny of patient history and physical record of CMRI Hospital, Kolkata, it reveals that the complainant underwent kidney stone surgery in the 1994 and 2008 along with appendectomy in the year 2008 and this fact was not disclosed at the time of inception of the policy and as per terms and conditions the claim was under preexisting disease as per exclusion clause of the policy.
In this context, we think, O.P.-1 had also the liability or duty to perform a medical check up of an insured person who are attended at the age of 50 years before renewal of existing policy but in the instant case O.P.-1 did not do so. Moreover, O.P.-1 is unable to establish their objection for settling the claim and paid the amount as per terms and conditions of the policy at a belated stage i.e. after receiving the legal notice.
On scrutiny of the case record, we find that the complainant lodged his claim for reimbursement before O.P.-1 after 18/08/2014 i.e. after discharging from the Hospital with all relevant documents. Thereafter, complainant repeatedly knocked the doors of O.P.-1 by personal visits, sending letters by post and served legal notice but O.P.-1 deliberately withheld the claim by a flimsy ground of preexisting disease for dragging the settlement of the claim of the complainant. But the O.P.-1 failed to prove its own stand point.
It also appears from the record that complainant filed this complaint on 18/08/2016 and O.P.-1 received the summon on 10/09/2016 and appeared before this Forum on 23/09/2016 and O.P.-1 settled the subject claim by sending demand draft of Rs.2,02,700/- on 21/09/2016 though it was drawn on 29/08/2016 by O.P.-1. More so, O.P.-1 admitted in its W.V. that after receiving the legal notice they reviewed the claim and disbursed immediately thereafter without prejudice by issuing demand draft for Rs.2,02,700/- bearing No.948989 dated 29/08/2016 drawn on HDFC Bank, Stephen House, 4 B.B.D. Bag, Kolkata. From the fact and statement of O.P.-1 it reveals that O.P.-1 deliberately withheld the claim of the complainant about two years, only on a flimsy ground of preexisting disease, which has no leg to stand of its point for objection.
It appears from the evidence of the complainant that he received only Rs.2,02,700/- out of his claim amount of Rs.2,09,000/-.
Proforma O.P. i.e. O.P.-2 has no liability as O.P.-2 had no relation for payment of the subject claim of the complainant and they were not the insurer on the material point of time.
In view of the above facts and discussions, we think that O.P.-1 deliberately withhold the claim reimbursement bill of the complainant for which complainant had to suffer mental and harassment and monetary loss and O.P.-1 is clearly deficient in rendering service being a service provider. From this aspect complainant is entitled to get relief as prayed for.
In result, the case succeeds.
Hence,
Ordered
The case be and the same is allowed in part on contest against the O.P.-1 and dismissed against O.P.-2.
O.P.-1 is directed to pay an amount of Rs.50,000/- towards compensation for causing harassment , mental pain and agony apart from litigation cost of Rs.10,000/- to the complainant within one month from the date of this order.
Failure to comply with the order will entitle the complainant to put the order into execution u/s.25 read with Section 27 of the C.P. Act and in that case OP shall be liable to pay penal damage at the rate ofRs.5,000/- per month to be paid to this Forum till full and final satisfaction of the decree.
