The case of the Complainant is as follows. This complainant was admitted to Neotia Getwel Healthcare Centre (behind City Centre, Siliguri ) on 03/08/2019 with sudden chest pain and then went through Angioplasty with the diagnosis of CAD Acute anteroseptal wall MI, CAG - Single vessel coronary artery disease, under Dr Rajesh Nanda (Annexure 1 - Discharge Summary of the complainant dated 08/08/2019 along with bills of treatment from 03/08/2019 to 08/08/2019). That the complainant states that at the time of admission, some relative of the complainant stated before the proforma op no 3 that the complainant had hyperthyroidism since last 3 years and hypertension since last 5 years .The same was reduced in writing and the son of the complainant signed without giving a proper look as the son of the complainant and wife of the complainant were under mental and physical stress because of the serious condition of the complainant. The nursing home staff on the basis of the said information sent the wrong information to Op No 1.Be it mentioned here that the complainant has acquired a Health Policy from the Cholamandalam MS General Insurance Company Ltd. Vide policy no 2856/00221740/000/00, valid from 12/02/2018. (Annexure 2- Details of policy no 2856/0022 1740/000/00, valid from 12/02/2018). The complainant states that immediately thereafter, the very next morning, when the wife and son of the complainant informed the proforma OP no 3 about the wrong information, the concerned staff of the proforma OP no 3 replied that it would not matter at all and he would manage with a past prescription of the complainant by the family doctor and a self declaration by the wife of the complainant. Later the staff of the proforma 0.P no.3 informed the wife of the complainant that a certificate was sought for along with the prescription dated 11/06/2019 from the family doctor, Dr. Pulak Kr. Saha, regarding the past illness of the complainant, So the wife of the complainant submitted a Certificate dated 06/08/2019 by the family doctor, Dr. Pulak Kr Saha so that the primary wrong information could be rectified early. The complainant states that the 0.P no 2 rejected cashless request first and then also rejected the reimbursement request of the complainant on the basis of pre-existing disease. (Annexure 4 - Health Claim Repudiation Letter dated 19/09/2019). the complainant states that the O.Ps have stated in the repudiation letter dated 19/09/2019 that the complainant has diabetes, which is entirely baseless as there are no medical reports to that effect nor there is any indication or medication for diabetes administered or prescribed to the complainant till the date of filing of this complaint. The wife and the son of the complainant contacted and requested the OP repeatedly to look into the matter properly and even the treating doctor at the proforma O P no 3 also issued a certificate for rectification of the wrong details stating in the certificate that the past history of Hypertension and Hyperthyroidism of the complainant was detected on 11/06/2019. The complainant states that the 0.P no 2 rejected the cashless request first and then also rejected the reimbursement request of the complainant on the basis of pre-existing disease. (Annexure 4 - Health Claim Repudiation Letter dated 19/09/2019). (Annexure 5 -Certificate issued by Dr. Rajesh Nanda dated 24/10/2019). Neither the OP no.1 nor the O.P no.2 ever stated to the complainant since the sale of the Policy on 12/02/2018 that the complainant had any case of "pre-existing" disease and under the compelling circumstances the complainant is running from pillar to post for reimbursement of his claim.
Complainant claim for the following directions
Direction to the O.P. no.1 and 2 to pay to the complainant jointly and/or severally the amount of Rs.2,00,000/- (rupees two lakhs only) towards reimbursement of the expenses incurred in treatment at the facility of the proforma O.P. no.3 with 12% interest.
Direction to the O.P. no.1 and 2 to pay to the complainant jointly and/or severally the amount of Rs. 1,00,000/-(rupees one lakh only) for the deficiency in service and harassment caused to the complainant on their part;
Direction to the O.P. no.1 and the O.P. no.2 to pay to the complainant the amount of Rs. 20,000/-(rupees twenty thousand only) towards the cost of the present litigation;
The Op No 1& 2 appeared before the Ld. court by filing Vocalatnama on 2/3/2020 but did not file WV before the Ld Court. So many opportunities were given to the ops to file WV before the Ld Court but the Ops did not take any steps in this regard. Thereafter on 25/4/2022 the Ld court was pleased to pass an ex-parte order against the Ops. The Complainant on 25/5/2022 has filed Evidence in affidavit before the Ld Court. The Ops on 17/6/2022 filed a petition to vacate the ex party order and on 1/11/2022 Ld court after hearing of both sides allowed the Ops to contest the suit for the ends of Justice. The ops has filed WV and their evidence in affidavit before the Ld Court That on 16/2/2023 the complainant filed additional evidence in affidavit before the Ld Court. The complainant and the Op No 1 & 2 has filed a questionnaire and reply to the questionnaire before the Ld Court. The Proforma Op No 3 has appeared before the Ld Court after vacating the ex parte order against him the Proforma Op No 3 has filed their WV and evidence in affidavit before the Ld Court.
The submission of O.P. NO.1. THE BRANCH MANAGER, CHOL MANDLAM MS GENERAL INSURANCE CO. LTD. & 0.P, NO. 2. THE OFFICER-IN-CHARGE, CHOLAMANDALAM MS GENERAL INSURANCE CO. LTD. Is as follows.
- These respondents do not admit and deny all the allegations made in different paragraphs of the petition and the petitioner is put to strict proof of all the allegations except those, which are specifically admitted hereunder.
- This claim-application is not maintainable on the jurisdiction ground alone. That the office of the O.P. No.1 is situated under the district of Darjeeling and the offices of the O.P. No.2 is also not situated within the district of Jalpaiguri again the residence of the complainant and the mentioned medical centre are situated in Siliguri, i.e. outside of the jurisdiction of this forum at Jalpaiguri.
- That the complainant was admitted to was admitted to Neotia Getwel Healthcare Centre on 03/08/2019 with sudden chest pain and then went through angioplasty with the diagnosis of CAD Acute anteroseptal wall M1, CAG-Single vessel coronary artery disease, under Dr. Rajesh Nanda and these 0.P.s have never by any means denied the matter of admission of the complainant on that date in the stated medical Centre and for his physical conditions as stated thereon. That the annexure No.1, "Discharge summary' of the 9 pages annexure as filed by the complainant, itself shows under the headings of "Final diagnosis", "History of present illness and Past medical history it has been specifically mentioned about "Hypertension and "Hypothyroidism". The said certificate also suggests a medicine for hypertension in serial No.7 of the list of medicines and by these medical documents the respondent company came to know about the existence of pre pre-existing deceased, as mentioned above. The medical report or prescription as supplied by the complainant itself suggests the complainant was suffering from pre-existing diseases, like diabetes and hypertension. the complainant who failed to establish the real cause of his claim with cogent evidences, he shouldn't pray for deficiency in service or unfair trade practice from the part of the respondents by any means, as these respondents are bound by terms and conditions of the policy document and unable to settle a claim which is not based on required proper document.
On the basis of the upper mention argument the opposite parties prayed for dismiss the instant complainant with cost.
POINTS FOR CONSIDERATION
- Is the Complainant Consumer as per provision under Section 35 of the C.P. Act,2019?
- Has this Commission jurisdiction to entertain the instant complaint?
- Have the O.Ps any deficiency in service, as alleged by the Complainant?
- Whether the Complainant is entitled to get any relief/reliefs, as prayed for?
DECISIONS WITH REASONS
Point Nos.1
Complainant has acquired a Health Policy from the Cholamandalam MS General Insurance Company Ltd. (OP-No- 1 & 2) Vide policy no 2856/00221740/000/00, valid from 12/02/2018. (Annexure 2- Details of policy no 2856/0022 1740/000/00, valid from 12/02/2018). Complainant is a consumer under the Ops as defined under Section 35 of C.P Act 2019.
Point Nos.2
The contesting ops claimed that the office of the O.P. No.1 is situated under the district of Darjeeling and the offices of the O.P. No.2 is also not situated within the district of Jalpaiguri again the residence of the complainant and the mentioned medical centre are situated in Siliguri, i.e. outside of the jurisdiction of this forum at Jalpaiguri. `the complainant files an affidavit and stated that he is a resident of Kundu complex , 2nd Mile, sevok Road, siliguri , P.S- Bhaktinagar, Dist-Jalpaiguri. Complainant also files copy of his voter identity card and aadhaar card (Both are in jalpaiguri district) to prove is residential address. This commission has both pecuniary and territorial jurisdiction to entertain the complaint. Both the points are thus disposed of in favour of the Complainant.
Point Nos.3 & 4
In their written version (Page 5 Para 15) and in their evidence on affidavit (page -4, para 14) stated as under
“Rather prior to knowing the fact of a pre-existing deceased the insurers had prepared a health assessment sheet, based on the treatment of angioplasty having a sub-limit of Rs. 1,00,000/-(Rs. One Lakh) and for angiography and Rs20,000/-(Rs. Twenty Thousand) for sub-limit. In the said computation sheet an amount of Rs.77,778/-(Rs. Seventy-seven Thousand Seven Hundred Seventy Eight) is included under the head of Total Disallowance which is deducted under the heads of Coronary Angiography, Coronary Angioplasty as fixed in the page 11 of the terms and conditions of the policy under clause No.3.1.4 (sub-limits) serial Nos. 14,15. Thus the total payable amount is of Rs. 1,20,000/-(Rs. One Lakh Twenty Thousand) by Dr. Basant, the consultant doctor of the respondents....Annexed Computation Sheet”
This is confusing that when OP saw that their appointed doctor was considering for giving 1, 20,000/- to the complainant, then why the O.P did not give that to the Complainant and cancelled his entire claim as pre existing disease clause?
The doctor who has treated the patient can say the best about this. In this case the doctor has detailed all about his treatment.
IN THE SUPREME COURT OF INDIA OM PRAKASH AHUJA VERSUS RELIANCE GENERAL INSURANCE CO. LTD. ETC.
Medical Insurance – “Once there is a valid insurance policy in favour of a
person, the claim for reimbursement of the expenses incurred must be
paid. Once the insurance company has accepted that concealment of a
disease at the time of purchasing the policy was not material as it was not
related to the disease”
CIVIL APPEAL NO. 6778 OF 2013 THE SUPREME COURT OF INDIA stated as under
“An insurance contract is a contract of the utmost good faith, and I
do not think it is consistent with that required good faith that an
insurer should present to an insured an alteration in the previously
agreed law and jurisdiction provisions of their proposed contract
without making that clear to the insured”.
In Haris Marine Products vs Export Credit Guarantee ... on (CIVIL
APPEAL NO. 4139/2020)25 April, 2022 the hon’ble Supreme Court of
India has observed as follows…. “an ambiguous term in an insurance
contract is to be construed harmoniously by reading the contract in its
entirety. If after that, no clarity emerges, then the term must be
interpreted in favour of the insured, i.e., against the drafter of the policy”.
In Life Insurance Corporation Of ... vs Pramila Basak on 20
May, 2021 the hon’ble National Consumer Disputes Redressal
Commission New Delhi in Revision Petition No. 414 Of 2020 (Against the
Order dated 17/12/2019 in Appeal No. 232/2018 of the State Commission
West Bengal) observed as follows…
“The insurance contract being a contract of utmost good faith is a two-way
door. The standards of conduct as expected under the utmost good faith
obligation should be met by either party to such contract.”
We find that the Complainant has successfully proved her case in part.
In the instant case, the copy of the insurance policy was filed by the complainant. The total medical claim of the complainant was Rs. 2, 00000/- (Two lakh only). The computation sheet made by the doctor appointed by the opposite party recommend that the amount payable Rs.1.20000/-. The repudiation of medical expenses reimbursement claim by the opposite party is not justified. O.Ps (1&2) are liable for deficiency of services and unfair trade practice according to consumer protection act 2019.
Hence, It is
O R D E R E D
That the case C.C./07/2020 be and the same is allowed on contest against the O.P- Number 1&2 with cost of Rs. 5,000/- (Five Thousand Only) payable to the complainant and dismiss on contest against POP-1.
O.P. No. 1 & 2 is to pay Rs. 2.00000/-. (Two lakh only) to the Complainant along with interest thereon @ 8% p.a. from 08/08/2019 till the date of payment within 30 days from this date..
O.P No. 1 & 2 has to pay Rs. 5.000/- (Five thousand only) to the consumer legal aid account of this commission.
Failing which the Complainant is at liberty to execute the decree according to law.
