Judgment : Dated – 01.08.2016
This is a complaint made by one Samir Kr. Ghosh against OPs Star Health and allied Insurance Company Ltd. Who are three in number representing different offices of their Company, praying for a direction upon them to settle the claim amount of Rs.98,786/- with interest at the rate of 12% p.a. and compensation to the tune of Rs.1,00,000/- and litigation cost of Rs.20,000/-.
In brief the facts are that the Complainant being the senior citizen purchased red carpet Insurance Policy from OP on 25.9.2013. Thereafter, the policy was renewed for the period from 25.9.2014 to 24.9.2015.
During subsistence of this policy Complainant suffered several ailments and went to Fortis Hospital and Kidney Institution on 13.12.2014, where he was admitted for removal of kidney stone on 8.7.2015 and operated upon by Dr. Subhash Das on 9.7.2015. He was discharged on 12.7.2015. During this period Complainant incurred expenditure to the tune of Rs.98,786/- which includes in patient treatment expenses to the tune of Rs.83,786/-.
Complainant lodged complaint for reimbursement of Rs.98,786/-. But, was not paid the amount. He was shown exclusion clause No.4 and ultimately his claim was refused. So, Complainant filed this case.
OP filed written version and denied all the material allegation of the complaint. OP categorically stated that Complainant had a policy for a period from 25.9.2014 to 24.9.2015. Further, OP has mentioned that the Complainant has pre-existing disease and during the first year that is between 2013-2014 made a claim of Rs.33,424/-. Further, OP has asserted that for removal of Kidney stone maximum amount permissible is Rs.20,000/-. So, OP prayed for dismissal of this case.
Decision with reasons
Complainant filed affidavit-in-chief where he has asserted the facts mentioned in the complaint, against this OP No.3 has filed questionnaire which Complainant has replied.
OPs have filed evidence on affidavit where they have asserted the facts which they have mentioned in the written version, against this Complainant has put certain questions to which OP has replied wherein OP in answer to question No.14 has stated that they asked for certain paper and since the Complainant did not furnish the claim was refused. Both sides have filed written argument.
Main point for determination is whether the Complainant is entitled to the reliefs as prayed for.
On perusal of prayer No.1 it appears that the Complainant has prayed for payment of Rs.98,786/- with interest of 12%. However, it appears that the Complainant has stated that he spend Rs.83,786/- at Fortis Hospital.
Further, it appears that the claim was repudiated on the basis of clause 4 of the policy which excludes removal of renal stone in the first year. Surprisingly OP has insisted that the policy was in the first year, whereas Complainant has mentioned that for the first time he took policy for the period from 25.9.2013 to 24.9.2014 and it was renewed for the next year. This fact has been admitted by the OP in page No.3 of written version wherein it is clearly stated that during first year policy Complainant was admitted to Kasturi Medical Centre.
So, the exclusion clause 4 as per terms of policy is not applicable.
Ld. Advocate for OP made a strong argument that Complainant has pre-existing disease which he did not disclose. However, it appears from page 4 of written version that medical team of OP examined Complainant and by letter dated 5.7.2014, 1.9.2014 and 9.8.2014 asked Complainant to furnish certain documents which he allegedly did not produce.
OPs have taken this as a plea to repudiate the claim. In our view this view cannot form the basis of refusing the claim and if such was the situation OPs should have refused to ensure the Complainant for the 2nd year which they did not do and accepted the premium. Since, OPs accepted the premium, they are obliged to reimburse the medical expenses during hospitalisation.
The allegation of OP in case of stone removal only Rs.20,000/- is permissible does not find place in the policy which has been filed before this Forum.
It appears that both the sides have suppressed some facts and so a balance has to be maintained by allowing Rs.50,000/- in favour of the Complainant. It is because if the case is dismissed due to the fact that Complainant claim is excessive it will be prejudicial to Complainant and in favour of the OPs who have not discharged their obligation by discarding the claim and making attempt to repudiate the claim on flimsy ground that they are asserting about clause 4 of the policy where it is clear that the policy in favour of Complainant was in the 2nd year.
Hence ordered
CC/05/2016and the same is allowed on contest in part. OPs are directed to pay Rs.50,000/- to the Complainant within two months of this order by A/C Payee Cheque on production of original receipt showing expenses made during hospitalisation. They are also directed to pay Rs.10,000/- as litigation cost within the same period in default both the amount shall carry an interest of 12% p.a. after two months of this order till realisation.
Since, no details appear to have been proved by the Complainant over award of compensation, the prayer for compensation stands rejected.
