DATE OF FILING : 29-06-2012.
DATE OF S/R : 10-08-2012.
DATE OF FINAL ORDER : 21-12-2012.
Shri Subhendu Chatterjee,
son of late Surya Kumar Chatterjee,
residing at Bazarpara, P.S. Uluberia,
District –Howrah---------------------------------------------------- COMPLAINANT.
- Versus -
1. The Branch Manager,
National Insurance Company Limited, Uluberia Branch,
Bazarpara, P.O. & P.S. Uluberia, District – Howrah,
PIN – 711316, and also registered office
at 3, Middleton Street, Kolkata,
PIN – 700071.
2. MEDSAVE HEALTH CARE ( TPA ) LTD.
1/1, Camac Street ( 3rd Floor ),
Kolkata – 700016.--------------------------------------------------OPPOSITE PARTIES.
P R E S E N T
President : Shri T.K. Bhattacharya, M.A. LL.B. WBHJS.
Member : Shri P.K. Chatterjee.
Member : Smt. Jhumki Saha.
F I N A L O R D E R
1. The instant case was filed by complainant U/S 12 of the C.P. Act, 1986,
as amended against the O.Ps. alleging deficiency in service U/S 2( 1 )( g ), 2( 1 )( o ) of the C.P. Act, 1986 wherein the complainant has prayed for direction upon the O.Ps. National Insurance Company Ltd. to pay the claim amount of Rs. 2,00,000/- and for further sum of Rs. 12,00,000/- as compensation for harassment, mental agony as the o.p. insurance company repudiated his medi claim on the ground that the complainant Subhendhu Chatterjee suppressed the history of his Diabetes and Hypertension ailment.
2. The o.p. no. 2 in spite of service of notice did not appear. So the case was
heard ex parte against the o.p. no. 2.
3. The o.p. no. 1 in their written version contended interalia that though the
complainant took the Parivar Medi claim Policy together with his wife on and from 24-02-2010 declaring his Diabetes history paying additional charge of 10% of the premium, suppressed that he was a patient of Hypertension for last 10 years ; that the disease preexisted and comes within the purview of Exclusion Clause 4.1 of the policy and as such the complaint should be dismissed.
4. Upon pleadings of both parties two points arose for determination :
i) Is there any deficiency in service on the part of the O.Ps. ?
ii) Whether the complainant is entitled to get any relief as prayed for ?
DECISION WITH REASONS :
5. Both the points are taken up together for consideration. Admittedly the complainant is a Parivar Medi Claim Policy holder for a sum of Rs. 2 lakh from 2010 to 2011, 2011 to 2012, 2012 to 2013. When the complainant fell ill due to sudden cardiac problem, blockage of heart was detected in the Fortis Hospital at Calcutta and accordingly on 09-08-2011 open heart surgery was conducted upon the petitioner. The enclosures reveal that the complainant observed all the necessary formalities and submitted his claim before the o.ps. but unfortunately the claim was repudiated on the ground of preexisting disease which comes within the Exclusion Clause of 4.1. Ld. Lawyer for the o.p. insurance company argued that the insured patient is a known case of Diabetic for 7/8 years and dependent on insulin. He further argued that the patient is hypertensive for last 10 years. He further argued that the claim was repudiated as the complainant suppressed his preexisting disease.
6. Now the pertinent question arises how the complainant can be made guilty of suppression of fact. When he initiated his medi claim policy, the o.p. insurance company has sufficient opportunity to put him before any medical board at their behest. Ultimately, no such board examined the complainant on the date of initiation of the medi claim policy. In absence of any medical investigation of the complainant, he cannot be to blame for suppression. That he is a patient of hypertension was detected on 04-07-2011 and not before that. A commoner cannot identify the inherent ailment embedded in him. So good of the complainant that he declared before the insurance authority that he was a patient of Diabetis for last 7/8 years. The o.p. insurance company only to avoid the payment of the medi claim has picked the Exclusion Clause of 4.1 very conveniently shifting the blame of suppression upon the complainant. Had the complainant being a patient of hypertension he would have taken medicine for such treatment. The o.ps. never asked for any medical report or document at the time of accepting the proposal.
7. We are, therefore, of the view that the o.p. insurance company committed gross deficiency in service in repudiating the bonafide claim of the complainant. They have no way escape from the rigours of law. We have examined the enclosures meticulously. The o.p. insurance company was thoroughly unjustified in turning a deaf ear to the claim of the complainant. This is a fit case where the prayer of the complainant shall be allowed. Both the points are accordingly disposed of.
Hence,
O R D E R E D
That the C. C. Case No. 70 of 2012 ( HDF 70 of 2012 ) be allowed on contest with costs against the O.P. no. 1 and ex parte without cost against o.p. no. 2.
The O.P. no. 1, Branch Manager, National Insurance Company Ltd., Uluberia Branch, Bazarpara, Howrah, be directed to release the medi claim to the tune of Rs. 2,00,000/- to the complainant within 30 days from the date of this order failing the claim shall carry interest @ 12% per annum since the date of submission of his claim on 04-07-2011 till satisfaction.
The o.p. no. 1 insurance company shall further pay a sum of Rs. 30,000/- as compensation for causing prolonged harassment and mental pain to the complainant.
The complainant is further entitled to a litigation cost of Rs. 5,000/-.
The complainant is at liberty to put the decree into execution after expiry of the appeal period.
Supply the copies of the order to the parties, as per rule.
