DATE OF FILING : 31.03.2016.
DATE OF S/R : 05.05.2016.
DATE OF FINAL ORDER : 19.07.2017.
Sri Biswanath Paul,
son of late Narendra Nath Paul
of 33, Raj Ballav Saha Lane,
Howrah 711101. ……………………………………………………… COMPLAINANT.
1. Star Health And Allied Insurance Company Limited,
represented by its Director,
having its registered office
at 1, New Tank Street Valluvarkottam High Road,
Nungambakkam, Chennai 6700034.
2. Star Health And Allied Insurance Company Limited
having its branch office at Parmer House, 3rd floor,
P – 4, Golabari, District Howrah,
PIN 711101 and Corporate Office KRM Centre,
6th floor, No. 2, Harrington Road, Chetpet,
Chennai 600031. …………………………………………OPPOSITE PARTIES.
P R E S E N T
Hon’ble President : Shri B. D. Nanda, M.A. ( double ), L.L.M., WBHJS.
Hon’ble Member : Shri A.K. Pathak.
Hon’ble Member : Smt. Banani Mohanta ( Ganguli ).
F I N A L O R D E R
- This is an application U/S 12 of the C.P. Act, 1986 filed by the petitioner, Sri Biswanath Paul, praying for a direction upon the o.ps., Star Health And Allied Insurance Company Limited & another, to reimburse the hospitalization claim amount of Rs. 1,10,692/- in favour of petitioner and to pay Rs. 1 lakh as compensation and Rs. 50,000/- as cost of proceeding.
- The case of the petitioner is that he purchased one medi-claim insurance policy being no. P/191113/01/2015/003597 under the Senior Citizen Red Carpet Insurance Policy with sum assured of Rs. 2 lakhs with cover policy period from 20.12.2014 to 19.12.2015 and paid regular premiums. Later on he was admitted in Rama Kriishna Mission Seva Pratishthan for treatment of HTN/LBBB Heart Attacks from 10.3.2015 to 20.3.2015 and incurred huge expenses amounting to Rs. 1,82,267/-. The o.ps. paid him only Rs. 71,575/- and not paid the rest claim even though the petitioner went on paying Rs. 9,500/- as early premium. The petitioner sent a letter on 14.10.2015 through his advocate to the o.p. and also the petitioner approached the o.p. on several occasions. Later on the petitioner wrote a letter to the o.ps. requesting them to know the fate of his claim on 14.10.2015. The o.ps. failed and neglected to reimburse his claim in stead they raised dispute and refused to pay the medical policy in favour of the petitioner compelling the petitioner to file this case.
- The o.p. no. 2, Star Health And Allied Insurance Company Limited, with branch at Parmer House, 3rd floor, P 4, Dobson Lane, New Howrah Bridge Approach Road, P.S. Golabari, appeared in the case and filed the written version denying the allegations made against them and stating that the petitioner has no cause of action against the o.ps. to file this case and the application is defective, incomplete, suppressive of material facts and not maintainable in the eye of law. The o.ps. agreed that the petitioner had a policy of Senior Citizen Red Carpet Insurance Policy being no. P/191113/01/2015/003597 and during subsistence of the policy on 27.4.2015 the petitioner lodged a claim and the o.p. scrutinized the same and reimbursed Rs. 71,575/- as the patient suffered from Grade II diastolic dysfunction and all these denote chronic heart disease subsisting for many years and the panel doctor of the o.p. opined that prior to inspection of the policy the petitioner has suffered from the diseases which was considered as preexisting disease as per opinion of medical team and on the basis of the same they reimbursed Rs. 71,575/-. As per Condition no. 5 of the policy document wherein the terms and conditions of the policy are clearly mentioned and our Hon’ble Apex Court also observed in the same tune in the case of “Vikram Greentech ( 1 ) Ltd. & Anr – vs. – New India Assurance Co. Ltd.’ as reported in 2013 ( 2 ) CPR page 315 ( NC ).
- Upon pleadings of parties the following points arose for determination :
- Is the case maintainable in its present form ?
- Whether the petitioner has any cause of action to file the case ?
- Whether there is any deficiency in service on the part of the O.Ps. ?
- Whether the complainant is entitled to get any relief as prayed for ?
DECISION WITH REASONS :
- All the issues aretaken up together for the sake of convenience and brevity for discussion and to skip off reiteration. In support of his case the petitioner filedaffidavit as well as document being policy document wherefrom it is noticed that the policy no. P/191113/01/2015/003597 was a policy ofSenior Citizen Red Carpet Insurance Policy and the insured was present petitioner, Sri Biswanath Paul, with age 66 years 9 months during the covered policy period starting from 20.12.2014 to 19.12.2015 and it is further mentioned therein that in the column asking for details of prefixing disease relating to the insured there is a clear mention ‘no’ that isthe petitioner had declared that he had no preexisting diseases and the same was accepted by the o.p. insurance company. Heard the ld. counsel for the petitioner as well as the o.p., insurance company. The counsel for the petitioner submitted that the o.p. company paid only a part of the bill submitted by the insured and only paid Rs. 71,575/- and there is balance of Rs. 1,10,000/- which was not paid by the insurance company. Ld. counsel for the o.p. submitted that the insurance company cannot go beyond the terms and conditions of the policy and thus as per terms of the policy they paid the expenses after deduction of certain percentage as mentioned in the policy. This Forum had gone through premium receipt showing that the petitioner paid Rs. 9,500/- for the period 2014 – 2015 and the policy document for Senior Citizen Red Carpet Insurance Policy in the name of the petitioner, Biswanath Paul, it is noticed that the premium was duly paid for the policy from 20.12.2014 to 19.12.2015 and the insured sum ofRs. 2 lakhs. The medical document ofRama Kriishna Mission Seva Pratishthan showing that the petitioner was admitted in the said hospital for treatment of HTN/LBBB Heart Attacks from 10.3.2015 to 20.3.2015 and it was further revealed in the in the Echo cardiogram report that concentric LVH, Grade II diastolic dysfunction and the same denote chronic heart disease and such symptoms subsisting for many years. Ld. counsel for the o.p. further submitted that in their reply to the lawyer’s notice they stated in their letter dated 26.10.2015 that such Grade II diastolic dysfunction denoted chronic heart disease which takes more than many years and hence it was a preexisting diseases and as per policy terms and conditions 50%co-pay is applicable to each and other claim arising out of preexisting disease and so they made such part payment. As per the Policy condition no. 5 of the policy. The ld. counsel also mentioned the judgment of the Hon’ble Apex Court in the case of“Vikram Greentech ( 1 ) Ltd. wherein the Hon’ble Court opined that the terms and conditions as contained in the subjectpolicy are binding on both the insured and the insurer and any deviation thereof is tantamount to recasting or rewriting of the insurance policy and insurance agreement. In the proposal form there is a clear mention that the petitioner submitted therein about the details of preexisting disease in the negative but the medical documents of Rama Kriishna Mission Seva Pratishthan though not filed before the Forum yet the petitioner yet the petitioner himself stating in his petition that he was admitted in the hospital for treatment of HTN/LBBB Heart Attacks on 10.3.2015 to 20.3.2015 and in his letter to the o.p. dated 11.4.2015 the petitioner submitted that he suffered a major heart attack on 10.3.2015 which amounted to Grade II diastolic dysfunction which denoted chronic disease which takes more than many years and thus as per the terms 50% co-pay is applicable to the claim arising out of preexistingdiseases.
Thus keeping in mind the medical documents and the communications between the parties and also the medical literature and the judgment of the ApexCourt this Forum finds that this was a case where the heart attack of the petitioner was nothing but result of preexisting diseases wherein as per the policy terms and conditions the o.p. paid 50% co-pay which was applicable in such claim and thus they rightly dispose of the claim application of the petitioner as the SupremeCourt opined that the parties are bound to abide the terms and conditions of the policy documents and any deviation from the same would amount recasting and rewriting the policy document.
In view of above the issues are decided against the petitioner resulting which the case of the petitioner fails.
Court fee paid is correct.
Hence,
O R D E R E D
That the C. C. No. 127 of 2016 be and the same is dismissed on contest without costs against the O.Ps.
Supply the copies of the order to the parties, free of costs.
DICTATED & CORRECTED
BY ME.
( B. D. Nanda )
President, C.D.R.F., Howrah.
