Date of Filing: 29.10.2018 Date of Disposal: 03.05.2023
Complainant :Mamata Nandi, W/O- Nandadulal Nandi resident of Vill-Jagdabad, P.O.-Panchkula, P.S.-Burdwan-Sadar, Dist. Purba Bardhaman, Pin 713141, Phone-9474483962
-VERSUS -
Opposite Party : Star Health and Allied Insurance Company Ltd. Burdwan Branch, Represented by its Branch Manager, having its office at 39/37A, Parbirhata, P.O. Sripally, Town & P.S. Burdwan, Dist. Purba Barddhaman, Pin 713103.
Present : Mohammad Muizzuddeen -Hon’ble President.
: Mrs. Lipika Ghosh - Hon’ble Member.
: Mr. Atanu Kr. Dutta. - Hon’ble Member.
Appeared for the Complainant : Survro Chakraborty Ld. Advocate
Appeared for the Opposite Party :Sourabh Dey Ld. Advocate.
F I N A L O R D E R
On 29.10.2018, the complainant - Mamata Nandi lodged an application u/S 12 of the C.P. Act against the O.P.
The case of the complainant, in brief, is that the O.P. issued a policy bearing No. P/191123/01/2016/004406 which was valid from 11.03.2016 to 10.03.2017 and total premium amount of the said policy of Rs.5,095/- and total coverage of the health was Rs.1,00,000/-
It is pertinent to mention that in respect of the said policy Mantu Nandi, the son of the complainant, is the proposer and complainant is the insured. After receiving the premium in the year 2017, the policy was renewed and policy bearing No. P/191123/01/2017/005932 and it was valid from 11.03.2017 to 10.03.2018. During the continuation of the said policy, the complainant started to suffer from breathing problem and as per advice of the treating doctor, she got admission at Life Care Nursing Home at Burdwan on 14.01.2018 where the treatment continued up to 18.01.2018. For which treatment amount Rs.37000/- has been incurred as treatment expenses. At the time of admission, the Nursing Home authority intimated the O.P. regarding such admission. After discharge of the complainant, her son received the claim form and other documents including bills, prescriptions and certificate of the treating doctor, submitted the same before the O.P. It is further stated that the son of the complainant received a letter dated 05.04.2018 from the O.P. and came to learn that the O.P. repudiated the claim of the complainant on the ground of pre-existing disease. In that letter the O.P. also mentioned that at the time of inception of the policy for the year 2016-2017, the complainant had not disclosed about the pre-existing disease and that is amount to misrepresentation of fact due to which they are not liable to make any payment to the complainant.
The complainant also received another letter dated 09.04.2018 along with letter dated 05.04.2018 where the O.P. cancelled the policy for the year 2018-2019. Moreover, the O.P. refunded the premium amount to your complainant vide Draft No.349558 dated 14.05.2018 amounting to Rs.5252/- along with letter dated 15.05.2018. After learning so, the complainant and her son became very much surprised because where the treating doctor issued certificate by declaring that the complainant was suffering from the breathing problem since January, 2018 then the O.P. repudiated the claim of the complainant on some vague, whimsical and self-made grounds which is nothing but a clear example of deficiency in service and unfair trade practice. The son of the complainant for several times verbally requested the O.P. to reconsider the claim but they did not pay any heed to the request. The O.P. repudiated the legitimate claim of the complainant and also cancelled the policy of the year 2018-2019 illegally. In this way the O.P. committed deficiency in service and negligence and unfair trade practice. Cause of action arose on and from 05.04.2018.
Upon this background, the complainant prayed for directing the O.P. to pay a sum of Rs.37,000/- to the complainant towards treatment expenses along with interest @10 % per annum by holding them liable for their deficiency in service and unfair trade practice along with a direction to reinstall the policy for the year 2018-2019. They also prayed for a direction to the O.P. to renew the subsequent insurance policies along with the direction to pay a sum of Rs.50,000/- as compensation for mental pain and agony and harassment suffered by the complainant and litigation cost of Rs.20,000/-.
The O.P. has contested the case by filing written version denying all the material allegations contending, inter alia, that the complainant has neither any locus standi nor any cause of action to file this instant complaint petition and that the instant complaint is wholly misconceived, groundless and unsustainable in law and that this Commission has no jurisdiction to entertain the complaint and that the complaint is bad for misjoinder of unnecessary party and non-joinder of necessary party and that the complaint is barred by limitation.
The specific case of the O.P. is that admitted the issuance of the above policy and renewal of the said policy, the claim of the complainant was repudiated in the second year policy that the Senior Citizens Red Carpet Health Insurance Policy issued to the complainant is governed by Maximum Limit of Liability's clause and co-pay conditions. From the claim form it is found that the insured Mantu Nandi has claimed an amount of Rs.35,713/-. It is found from the Discharge Certificate issued by Life Care Nursing Home, Burdwan that the insured patient Mamata Nandi was admitted in the said Nursing Home on 14.01.2018 at 11.30 am and was discharged on 18.01.2018 at 9.00am. Thus the insured Mantu Nandi submitted a claim form for reimbursement of Medical Expenses for the treatment of Chronic Obstructive Pulmonary Disease and Diabetes Mellitus. On scrutiny of medical record, it is found that PFT (Pulmonary Function Test) report dated 19.02.2018 shows Severe Obstructive Airway Disease with restrictive pattern, Chest X-Ray dated 15.01.2018 shows Bilateral Lymphadenopathy and based on these findings, it is confirmed that insured patient, Mamata Nandi has long standing Chronic Obstructive Pulmonary Disease (COPD) prior to the date of commencement of first year policy. The present admission and treatment of the insured patient Mamata Nandi is for non-disclosure of pre-existing COPD. At the time of the inception of policy, which is from 11.03.2016 to 10.03.2017, the insured had not disclosed the abovementioned Medical History/Health details of the insured person, Mamata Nandi in the proposal form, which amounts to misrepresentation / non-disclosure of material facts. Hence, the policy was cancelled with effect from 19.05.2018 with prior notice 09.04.2018 due to non-disclosure of COPD and the premium amount of Rs.5,252/-was refunded. This O.P. informed vide its letter dated 09.04.2018 to the complainant. The allegations of deficiency in service and unfair trade practice against the O.P. as made in the complaint are wholly misconceived, groundless, false and untenable in law.
Upon this background, the O.P. claims the dismissal of the case with a cost of Rs.10000/- as provided under law.
D e c i s i o n w i t h R e a s o n s
In order to prove the case, the complainant has filed evidence-on-affidavit and Xerox copies of document. The O.P. did not file any questionnaire as he was not willing to file submit the same. The W/V has been treated as evidence-on-affidavit on behalf of the O.P. The complainant filed questionnaire to the O.P. The O.P. filed reply to the said questionnaire. Both the parties filed written notes of argument.
Perused the complaint, written versions, evidence-on-affidavit and written notes of argument. We also perused the Xerox copies of document. The complainant corroborated the facts of the case depicted in the complaint by evidence on affidavit. The O.P. also corroborated his fact as the W/V has been treated on evidence-on-affidavit. Both the evidences of the parties are oath vs. oath. Now the picture of the case will clear from the documentary evidence. It is admitted that those polices were issued by the O.P. in favour of the complainant and subsequently the policies were renewed also. During continuation of the polices, the complainant started to suffering from breathing problem and as per advice of the Doctor, she was admitted at Life Care Nursing Home at Burdwan on 14.01.2018 and her treatment continued up to 18.01.2018 and for such Rs.37,000/- has been expended as treatment cost and the complainant claimed the said medical expenditure of Rs.37,000/- along with submission of documents, bills, prescription and certificate of the treating doctor etc. But it was refused by the O.P. on the ground that the complainant was suffering from per-existing dieses which amounts to misrepresentation of fact and she did not disclose the said fact of pre-existing disease at the time of inception of the insurance policy but the complainant clearly stated that the treating doctor issued certificate by declaring that the complainant was suffering from the breath problem since January, 2018 prior to inception of the insurance policy. During continuation of the insurance policy for the period from 2017 to 2018, the certificate dated 18.01.2018 issued by doctor support the said versions of the complainant.
Therefore, non-disclosure of the pre-existing disease by the complainant at the time of inception of the insurance policy does not arise at all.
It is the duty of the O.P. that at the time of issuing of the policy certificate, to enquire into the matter as to whether the insured person was suffering from any pre-existing disease or not.
In the instant case, no such incident happened as the certificate of the Doctor concerned clearly indicates that the complainant was suffering from the breathing problem since 14.01.2018 for which the treatment was given till 18.01.2018 in the alleged Nursing Home.
Therefore, the misrepresentation of the events or non-disclosure of pre-existing disease as raised by the O.P. cannot stand. The Xerox copies of document also shows that the complainant bears the medical expenses of Rs.37,000/- for her treatment.
Accordingly, the complainant is entitled to get relief in this case.
Having considered the facts and circumstances of the case and evidence-on-record, it can be said that the O.P. has committed deficiency in service and negligent in this case. As a result the case succeeds.
Therefore, the complainant is also entitled to get compensation and litigation cost in this case.
Hence, it is
O R D E R E D
that this case being No.184 of 2018 be and the same is allowed on contest against the O.P. but without any cost.
The O.P. is directed to pay a sum of Rs.37,000/- (Thirty Seven Thousand) only towards medical treatment expenses along with compensation of Rs.20,000/-(Twenty Thousand) only and litigation cost of Rs.10,000/- (Ten Thousand) only to the complainant.
The O.P. is also directed to reinstall the policy in the year 2018-2019 by receiving the refunded amount of Rs.5,252/-(Five Thousand Two Hundred Fifty Two) only from the complainant and the O.P. also directed to renew the subsequent insurance policy as per rules.
The O.P. is directed to the pay the above mentioned amount to the complainant by A/c payee cheque within a period of 45 days from the date of receipt of the order failing which the said amount shall carry interest @15% per annum till realization.
Let a copy of this order be supplied to parties on free of cost.
Dictated & corrected by me.
President
D.C.D.R.C., Purba Bardhaman.
Member Member President
D.C.D.R.C., Purba Bardhaman D.C.D.R.C., Purba Bardhaman D.C.D.R.C., Purba Bardhaman
