The case of the complainant in a nutshell is that the complainant once to ensure the health of his family members and also to avoid the unwanted trouble related with medical expenses had decided to cover themselves under the mediclaim policy of the O.P. company and after complying necessary formalities including medical check up of all of the family members. The complainant states that the medical check up procedure was arranged by the O.P. company i.e. the united India Insurance Company Ltd. through their own doctor. After medical check up the certificate was issued in favour of the complainant’s family and consider the eligibility to get the facility of family medicare policy. The complainant states that the original medical certificate is lying under the custody of the O.P. company. The complainant further states that O.P. No.1 is the local authority of United India Insurance Company Ltd. O.P. No.2 is the regional head of the said company. O.P. No.3 is the head authority of the said company and O.P. No.4 is the associates of the said company.
The complainant states and contends that in the year 2013, 1st July the wife of the complainant namely Smt. Tapasi Saha a disease namely critical venus thrombosis detected in the body of Smt. Tapasi Saha and she was admitted in Bangur Institute of Neuro Science at Kolkata on 20.7.2013 and thereafter to get benefit of the said family medicare policy the complainant submitted his claim form before the O.P. No.1 and it was accepted by the O.P. No.1 on 27.8.2013 and according to the direction of the O.P. No.1 through O.P. No.4 the complainant complied all the directions time to time and the complainant states that he was provided a claim form. Thereafter the complainant states that a letter dated 28.7.2015 the complainant was informed that the claim submitted by him has been cancelled on the ground that the inception date of policy is 18.5.2011 and the disease is pre-existing in nature and the disease is for three years which is against the condition provided in the clause 4.1 and for this reason the O.P. company denied the claim of the complainant amounting to Rs34,944/-. The complainant states that the findings of O.P. company are false, baseless and irrelevant and not maintainable in the eye of law and the disease is not predictable and the said disease effected the wife of the complainant long after the date of inception of the said policy and the symptoms of the said case had been relapsed long after date of inception. The complainant states that the acts and deeds of the O.P. company is arbitrary and whimsical and there is a gross negligency and deficiency of service on the part of the O.P. company. Thereafter the complainant through an Advocate’s letter requested all the O.Ps. to do the needful for the payment of claim amount of Rs.34,944/- within 30 days from the date of receipt of this letter but inspite of receiving the letter the O.ps. neither made any payment nor took any steps in favour of the complainant. Finding no other way the complainant has come before this Ld. Forum for necessary redressal. The complainant thus prayed before the Ld. Forum with a direction upon the O.P. company to pay compensation amounting of Rs.1,50,000/- for day to day harassment and mental agony.
That amongst the O.ps. the O.P. No.1 contested the case by filing written version denying the allegation leveled against them and the O.P. No.1 prayed that the written version should be treated as examination in chief. The O.P. No.1 in his written argument argued that as per clause 5.12 of the terms and condition of the policy medical check up is done only in case of exceeding 45 years. That at the time of taking policy Tapasi Saha was 36 years. So, it is clear no medical check up was conducted at the time of taking policy and the complainant is trying to misguide the Ld. Forum stating that medical check up was conducted. The O.P. No.1 further argued that the complainant made a claim stating that the a disease namely critical venus thrombosis was detected in the body of the Tapasi Saha and made a insurance claim accordingly. The O.P. company states that they denied the claim because the said claim does not fulfill the conditions enumerated in clause No.4.1. As per the said clause any pre-existing conditions as defined in the policy until 48 months of continuous coverage of such insured person have elapse, since inception of his/her with the company. The O.P. states that the medical name of the disease which the complainant’s wife has been suffering is superior Sagital Sinus Thrombosis. The O.P. further states that Tapasi Saha has a medical history of three years vascular headache and according to clause No.4.1 in the terms and condition it is a pre-existing disease in which 48 months of continuous coverage of such insured person is needed to make a claim. O.P. argues that 48 months continuous coverage is not completed in this case and the complainant is unable to prove his case beyond all reasonable doubt and also argued that complainant is not entitled to get any relief as prayed for.
Complainant filed Xerox copy of Family Mediclaim Policy in the name of Rajkumar Saha, Xerox copy of intimation letter to Rajkumar Saha by the Heritage Health Pvt. Ltd., Xerox copy of treatment sheet of Bangur Institute of Neuro Science. The complainant also filed evidence on affidavit and written notes of argument. O.P. No.1 filed written version and written notes of argument.
Points for decision
- Whether the complainant is a consumer?
- Whether there is any deficiency in service on the part of the O.P.?
- Whether the complainant is entitled to get relief as prayed for?
Decision with reason
All the points are taken up together for the easiness of discussion
In the light of the discussion here in above we find that the issues/points should be decided based on the above perspective.
Point No.1: Whether the complainant is a consumer of the O.P. ?
From the materials on the record it is transparent that the complainant is a consumer of the O.P. U/s.2(1)(d)(ii) of the Consumer protection Act, 1986 as the complainant insured his life and his family member before the O.P. So, he is entitled to get service from his service provider/insurer.
Point No.2 & 3:
Both the points are taken up together for easiness of discussion.
It is admitted fact that the complainant and his family member were agreed to took the policy on 18.05.2011 and complied all the necessary formalities. So, the complainant and his family member had covered themselves under the medicare policy of the opposite party and as per direction of the O.P. No.1 through the O.P. No.4 the complainant complied all the direction time to time. Thereafter as per terms and conditions of the O.P. company the complainant started making payment of premium regularly in favour of the O.P. company till the year 2014 which was valid till 17.5.2015. That on 1.7.2013 a disease namely critical venus thrombosis was detected in the body of the complainant’s wife Smt. Tapasi Saha and she admitted in Bangur Institute of Neuro Science on 20.7.2013. That thereafter to get the benefit of family medicare policy before the O.P. which was duly accepted by the O.P. No.1 on 27.8.2013. But thereafter unfortunately through a letter dated 28.7.2015 the complainant was informed that the claim submitted by the complainant has been found to be inadmissible on the ground that the inception date of policy 18.05.2011 of the O.P. company and the pre-existing nature of the disease of three years which is against the condition provided in the clause 4.1. In this regard the complainant mentioned the findings of the O.P. company are false, baseless and irrelevant one and not maintainable in law and in factual aspect the complainant states that the disease for which the claim is sought for is not a predictable one and the disease effected the wife of the complainant long after the date of the inception of the policy. The complainant states that he is a bonafide consumer of the O.P. company and due to deficiency of service and malpractice on the part of the O.ps. the complainant face a lot of trouble for which he is entitled to get compensation amounting to Rs.1,50,000/- only for his day to day harassment and being service provider the O.P. company cannot escape from this liability. Here the O.P. No.1 contested the case by filing written version and prayed before the Forum that the written version of the O.P. should be treated as examination in chief.
We do not find suppression of any material fact by the insured in the proposal form and OP has committed deficiency in repudiating claim on flimsy grounds.
Had she been suffering from superior Sagital Sinus Thrombosis prior to acceptance of policy then what was her problem to receive treatment from date of knowledge of suffering? No one would like to remain without treatment when she has sufficient funds to take treatment.
Merely because one is having superior Sagital Sinus Thrombosis may be without her knowledge, it cannot be said that she by suppressing her ailment received the policy. There is no material in the record to show that in any proposal form, it was concealed or mentioned by the LA that she was suffering from superior Sagital Sinus Thrombosis. There is no material to show that there was any earlier treatment in respect of any superior Sagital Sinus Thrombosis symptom. In absence of any treatment paper, no court/Forum can hold that there was some earlier pre-existing disease which was concealed by the complainant while making proposal for the insurance cover. Thus the defense which has taken by the OP Company was having no legs to stand so it is rightly discarded by this Forum.
It was pleaded on behalf of the complainant that if an insured is not aware of an ailment he may be suffering, nondisclosure thereof does not tantamount to suppression of material fact.
No documents in respect of treatment of the complainant before the acceptance of Proposal Forum are in the case record which corroborates that the complainant has been suffering from Thrombosis The OP failed to produce such document to deny the claim of the complaint that during the acceptance of proposal Form LA supplied the correct information regarding his health.
So, the life assured was unaware of her disease whether she was suffering from superior Sagital Sinus Thrombosis and his illness at the material point of time i.e. taking the insurance policy does not arise. He was not aware whether he will suffer from superior Sagital Sinus Thrombosis in the future and she/ her nominee have to make claim before the Insurance Company for which the Insurance Company by repudiating her/complainant’s claim destructed the myth of utmost on good faith.
Upon consideration of the evidence adduced by the parties, this Forum observed that the Insurance Company had failed to bring on record any proof in support of their plea that the deceased was suffering from any pre-existing disease at the time of obtaining the policy, there was no evidence to prove that the deceased was ever admitted for any treatment in a hospital for the alleged pre-existing disease at the time of obtaining the policy and that the medical evidence relied upon by the Insurance Company was neither supported by any corroborative evidence not did it prove that the said treatment had any nexus with the cause of superior Sagital Sinus Thrombosis. This Forum thus came to the conclusion that there was no suppression of any material fact by the life assured and therefore, in not settling the claim of the complainant, there was deficiency of service on the part of the Insurance Company, causing great hardship, financial loss and mental agony to the complainant.
So, we are in a considered opinion to allow the complaint as policy holder was not suffering from any disease when she signed the policy proposal of this OP Insurance Company and OP could not prove the same. We direct the OP Insurance Company i.e. the OP No.1 to pay the sum of Rs.34,944/- including interest @ 10% from the date of repudiation of claim by the OP till realization in favour of the complainant.
It is evident that the O.P. has only evasively denied the complainant’s case and not able to substantiate any sort of defense story in the written statement.
From the above discussions it is crystal clear that the complainant has suffered at the deficiency of service on the part of the O.P. company for which the complainant is entitled to get relief as prayed for.
From the foregoing discussion we are in the opinion that the complainant has proved his case by adducing cogent documents. Further more the O.P. company has been failed to shaken
and /or penetrate and/or challenge the complainant’s case in any manner and the O.P. did not produce any document to show that the complainant’s case is not true and in absence of any kind of defense case and in absence of corroborative evidence and there for, the complainant could succeed on contest with cost. Hence, it is
Ordered
that the case No.CC 40/2016 be and the same is allowed on contest against the O.P. No.1 and exparte against the O.P. No.2 to 4 with a litigation cost of Rs.10,000/-.
The OP No.1 is directed to pay a sum of Rs.34,944/- to this complainant which he expensed during his treatment.
The O.P. No.1 is also directed to pay Rs.10,000/- to the complainant for harassment and mental agony and financial loss.
All the above payment should made by the O.P. No.1 to the complainant within 30 days from the date of this order, at the event of failure to comply with the order the O.P. No.1 shall pay cost @ Rs.50/- for each day delay, if caused, on expiry of the aforesaid 30 days by depositing the accrued amount, if any, in the Consumer Legal Aid Account.
Let the copies of this order be supplied to the parties free of cost.
