In the District Consumer Disputes Redressal Forum, Murshidabad

Berhampore, Murshidabad.

Case No. CC/60 /2016

Date of filing: 26/04/2016                                                                  Date of Final Order:    19/05/2017

Pintu Das S/O- Lt. Laxman Das.

Vill.- Surulia Colony, P.O.- Barua.

P.S.-Beldanga. Dist- Murshidabad.……………………………...Complainant

- Vs-

 1).The Branch Manager.

 L.I.C  of India Berhampore Branch Office, Krishnath Road.

P.O.& P.S.- Berhampore. Dist.- Murshidabad.PIN.-742101

2). The Branch Manager.

 L.I.C  of India Beldanga Branch. Station Road.

P.O.& P.S.- Beldanga. Dist.- Murshidabad.PIN.-742133.

3). The Manager ( Health Insurance) LIC of India Divisional Office,

 K.S.D.O., Divisional Office ‘ Jeevan Prabha’,

 DD 5, Sector-1, Salt Lake City, Kolkata, PIN- 700064.

4). The Zonal Manager ( Health Insurance)

4, C.R. Avenue , Kol. 700072. …………….……….  Opposite Party

                          Before:      Hon’ble President, Anupam Bhattacharyya.

                                             Hon’ble Member, Samaresh Kumar Mitra.                                            

FINAL ORDER

Samaresh Kumar Mitra, Member.

       The case of the Complainant is that he opened a policy in LIC vide Table No.903 LIC’s Jeevan Arogya Vide policy being No.429941896 in which his mother Malina Das was the nominee. According to policy conditions nominee will also get medical benefits and claims. The said Malina Das was a joint policy holder as well as nominee. The mother of the policy holder Malina Das fell ill in severe illness and had been suffering from excruciating pain in her right wrist. Consequently complainants mother Malina Das was taken to a consultant Neuropsychistrist Dr.Ranjan Bhattacharyya at his Berhampore chamber on 22/04/2015. Thereafter blood of the complainant’s mother got tested at Laldighi Medical Centre but the condition of the patient got deteriorated as no fruitful result obtained following the prescription of Dr. Ranjan Bhattacharyya and MRI done. Having no other option mother of the complainant set for Chennai for better treatment and consulted with Dr. Vijay Raghavan P.V. (Ortho) and detected that the patient was suffering from a malignant disease called Right DE QUERVAIN’S disease. So she was admitted on 17/8/2015 for surgical operation in Sri Ram Chandra Hospital Porur, Chennai-600116. After the operation she was discharged on 20.08.2015 and came back home on 23.8.2015. Then the complaint went to Berhampore Rabindranath Research Centre at Berhampore for cutting the stitch of his mother on 28.08.2015 but they could not due to inefficiency so she was compelled to go to Chennai for untying the stitch.  Then the complainant deposited Xerox copy of treatment, Prescription, medicine voucher, discharge certificate and other relevant papers stating medical claims & benefit as entitled to in the branch office of the LIC at Berhampore on 23.9.2015. thereafter all relevant papers of his mother’s treatment, bill & voucher, then it was forwarded to the OP No.3 office and  he met bodily and narrated the KSDO regarding his mothers wrist operation and in regard to medical expenses and requested to settle the med claims and benefits within short span as he was in financial crunch. That the manager (HI) LIC of India Sub divisional Office KSDO (HO42) Jeevan Probha,DD-5 i.e. OP No.3 asked the complainant on  05.11.2015 to submit relevant papers in regard to his mother’s treatment, bill & Voucher of expenses, the complainant submitted all papers to make him satisfied, but the official of KSDO showed different type of excuses for not paying off the med claims. Thereafter he made a lot of correspondences to the OP and filed documents on different dates as depicted in the complaint petition. That the E- Meditem corporate office at Haryana acknowledged the claim petition and sent this complainant a claim requirement letter advising the complainant to submit some relevant papers in support of Mediclaim of his mother Malina Das. The officials of LIC (HI) rejected the claim of the complainant in triple reasons and by a rejection letter informed this complainant to get explanation regarding Dr. Ranjan Bhattacharyya’s prescription. Thereafter the complainant sent a legal notice stating amicable settlement to the LIC officials but of no result. Then the official of LIC(HI) sub divisional office K.S.D.O called the complainant on telephone on 18.3.2016 and after a discussion the said office advised the complainant to meet the Zonal office regarding claim settlement. The complainant meet the Zonal Officer in the office at 4, C.R.Avenue , Kol.-700072 and narrated his sorry plight and harassment and family crises but he could not took positive steps then he getting no alternative filed the instant complaint before this Forum for getting Rs.60,000 as Mediclaim, Rs.50,000 as harassment & mental agony, cost of proceedings and other reliefs as redressal.     

            The case of the OP, in brief, is that all the allegations made in different paragraphs by the complainant in his complaint are not admitted to be true and are denied the allegation as leveled against him.. The OP No.1 in his written version assailed that the complainant has taken the Jeevan Arogya policy bearing No.429941896 from Berhampore Branch on 18.12.2012. The complainant being principal insurer has added his mother Malina Das as dependant. As per terms and conditions of the policy bond complainant is eligible of getting benefits of Medical Expenses subject to policy is in force and complainant demands his claims in time with all required documents. In the instant case the complainant failed to submit all documents within time schedule. Though delay submission was condoned by LIC but TPA rejected the claims due to non submission of required papers. Requirements received from principle Insurer (Letter from PI, Prescription from Dr. R. Bhattacharyya and pathological report) were forwarded to TPA on 04.11.2015. But TPA had asked to provide the history and duration of Urtcaria, hemarrhoidectomy since when, certified by treating doctor (Dr. Vijayaraghvan) supported by the first consultation paper vide their letter dated 02.11.2015 & reminder dated 01.12.2016. Complainant Pintu Das submitted the prescription from Dr. Ranjan Bhattacharyya on 26.12.2015 and expressed his inability of submission of prescription from Dr. Vijayaraghavan. This OP has sent those to TPA on 06.01.2016. Thereafter the claim was rejected by the TPA on 02.2.2016 putting reason “Requirements called for: The policy holder did not comply with the requirements called for and claim is pending beyond even after repeated reminders. Hence the claim has to be rejected instead of keeping it open indefinitely”. As per record the claimant did not submit any further requirement and as per decision taken by TPA, they sent the claim rejection letter to Pintu Das. This OP mentioned the cause of rejection “H01- PRE-EXISTING ILLNESS IRRESPECTIVE OF PRIOR MEDICAL TREATMENT OR ADVISE”. He also averred that if complainant able to submit the required documents then he would get Rs.8800 that is Rs.2200 as hospital cash benefit and Rs.6600 for surgery. Since there is no fault, no service deficiency on the part of this OP, so compensation must not be payable to complainant and the complaint is liable to be dismissed.  

       The complainant filed evidence on affidavit which is nothing but replica of complaint petition and denial of written version.

       Argument as advanced by the agent of the opposite parties heard in full.

    From the discussion herein above, we find the following Issues/Points for consideration.

ISSUES/POINTS   FOR   CONSIDERATION

1. Whether the Complainant Pintu Das ‘Consumer’ of the opposite party?

2. Whether this Forum has territorial/pecuniary jurisdiction to entertain and try the case?

3. Whether the O.Ps carried on unfair trade practice/rendered any deficiency in service towards the Complainant?

DECISION WITH REASONS

   In the light of discussions here in above we find that the issues/points should be decided based on the above perspectives.

1. Whether the Complainant Pintu Das ‘Consumer’ of the opposite party?

               From the materials on record it is transparent that the Complainant is a “Consumer” as provided by the spirit of section 2(1)(d)(ii) of the Consumer Protection Act,1986.The complainant herein is the consumer of the OP, as policy holder insured his life through medical insurance and OP is the insurer.

(2).Whether this Forum has territorial/pecuniary jurisdiction to entertain and try the case?

            Both the complainant and opposite parties are residents/carrying on business within the district of Murshidabad. The complaint valued Rs.60,000/-  as medical expenditure in the course of treatment  of the mother of the complainant and Rs.50,000/-as compensation for mental agony and cost and other reliefs  ad valorem which is within Rs.20,00,000/- limit of this Forum. So, this Forum has territorial/pecuniary jurisdiction to entertain and try the case.   

 (3).Whether the opposite party carried on Unfair Trade Practice/rendered any deficiency in service towards the Complainant?

           It is well settled proposition of law that a contract of insurance is based on the principles of utmost good faith-uberrimaefidei, applicable to both the parties. The rule of nondisclosure of material facts vitiating a policy still holds the field. The bargaining position of the parties in a contract of insurance is unequal. The insured knows all the facts; the insurer is unaware of anything which may be material to the risk. Very often, it is the insured who is the sole person who has this knowledge. The insurer may not even have the means to find out facts which would materially affect the risk. The law, therefore, enjoins on the insured an absolute duty to disclose correctly all material facts which is within his/her personal knowledge or which he ought to have known had he made reasonable inquiries. A contract of insurance, therefore, can be repudiated for non disclosure of material facts.

The case of the complainant is that he is being the policyholder of OP insurance company and his mother being the nominee as well as beneficiary of the said policy treated before Dr. Ranjan Bhattacharyya at his chamber at Berhampore and after conducting investigation and others when the condition of the patient was deteriorating gradually then the complainant rushed to Dr. Vijay Raghavan P.V. and at first consulted with the said doctor at Sri Ramchandra Medical Centre in Chennai-116 thereafter as per advice of the treating doctor admitted at Sri Ram Chandra  Hospital Porur, Chennai-116 for surgical operation as she was suffering from DE QUERVAIN’S disease. After the successful operation mother of the complainant was released on20.08.2015 and subsequently she compelled to go to Chennai for cutting her stitch. After the treatment the complainant filed claim form before the OP who on their turn required necessary documents from the complainant and after getting documents they could not settle the claim of the complainant as the TPA rejected the same on the pretext that the cause of rejection “H01- PRE-EXISTING ILLNESS IRRESPECTIVE OF PRIOR MEDICAL TREATMENT OR ADVISE”. But the answering OP in his written version assailed that if the complainant able to submit the required documents then he would get Rs.8800.

    The advocate on behalf of the complainant assailed that the OP repudiated the valid claim of the complainant on a false plea that the patient was suffering from pre-existing disease but in fact the patient was totally unaware regarding her disease prior to accepting the policy by the complainant. As the claim of the complainant is reasonable and as per the policy so he is entitled to get redressal as prayed in the prayer portion of the complaint. The advocate on behalf of the OP vehemently opposed the claim of the complainant and he by showing the provisions of the health insurance plan that in the heading Major Surgical Benefit it is stated that the major surgical benefit will be payable only after the corporation is satisfied on the basis of medical evidence that the specified surgery covered under the policy has been performed.

   But perusing the case record we find that the OP could not produce even a scrap of paper from which we can infer that the patient was suffering from pre-existing disease. They rejected the claim of the complainant merely on the basis of assumption and presumption.     

   The Forum found that the patient Malina Das had no knowledge about the disease prior to accepting the policy by the complainant so he could not mention the history of disease in the proposal form. The company had repudiated the claim based on assumption about pre-existing disease. Only on the basis of assumption and presumption a claim under the policy cannot be repudiated. We can rely on the ruling of the National Consumer Disputes Redressal Commission (2008 CTJ 347) which said that most of people were totally unaware of the symptoms of the disease they were suffering. Hence insurance companies could not be allowed to take advantage of exclusion clause of pre-existing disease in a Mediclaim policy.

  From the above discussion we may safely conclude that the claim of complainant is valid and he could produce the xerox copies of treatment sheet as well as bills & receipts of hospital and doctor which seems to be reasonable and not exorbitant. Thus mere direction to the OP is sufficient to reimburse the expenditure that incurred during the treatment/surgery of the L.A. Malina Das.     

4. Whether the complainant proved his case against the opposite party, as alleged and whether the opposite party is liable for compensation to him?

               The discussion made herein before, we have no hesitation to come to a conclusion that the Complainant has abled to prove his case and the Opposite Party is liable to pay the amount that incurred during the treatment including interest for the surgery of the mother of this complainant whose life was also assured by the policy, as ascertained by this Forum.

ORDER

Hence, it is ordered that the complaint case being No.60/2016 be and the same is allowed on contest with a litigation cost of Rs.4000/- against the opposite parties Nos. 1to3.

               The Opposite Party Nos.1 to 3 are directed to pay jointly and/or severally a sum of Rs.25000/- including interest @8% p.a. to the complainant, since, the date of submission of claim form on 23.09.2015 within 45 days from  the date of receiving this order.

                At the event of failure to comply with the order the Opposite Party shall pay cost @ Rs.50/- for each day’s delay, if caused, on expiry of the aforesaid 45 days by depositing the accrued amount, if any,  in the fund of  ‘Consumer Legal Aid Account’.

Let a plain copy of this Order be supplied free of cost to the parties/their Ld. Advocates/Agents on record by hand under proper acknowledgement/sent by ordinary post forthwith, for information & necessary action.

           Dictated and corrected by me.

                        Member,                                                                                        President.