Hon’ble Mr. Sudip Niyogi, President
The Complainant files the instant case against the Ops u/s 12 the CP Act, 1986 on being aggrieved by the acts of the Ops. In a nut shell, the case of the Complainant is that he obtained Insurance Policy with the Ops initially in the year 2009-10 for himself, his wife, son and daughter @Rs.50,000/- each as assured value and since then, he renewed his Policy every year. Since the year 2016-17, the assured value of the Policy was enhanced to Rs.1 lakh each from the earlier assured value of Rs.50,000/-. At the time of the said renewal, he was advised by his Agent that he would get the benefit of his earlier Policy also. He also paid the premium of Rs.8575/-. As his wife was suffering from gall bladder pain, she had undergone operation at Dishery Health Point Pvt. Ltd., Malda on 26.04.18 with prior intimation to the Ops during the validity period of his Policy No.313202/48/2018/500. Ultimately, on 11.05.18, the Complainant submitted papers for reimbursement of expenses/claim comprising Rs.25,120/- for cost of operation including Bed, OT charges etc., Rs.5,860/- for cost of pathological tests and Rs.8,092/- for medicine bill, thus amounting to Rs.39,072/- in total. According to the Complainant, after about a lapse of two months of submission of application for reimbursement, the OP No.1 wanted to settle the claim by payment of Rs. 20,000/- only. Later, the Complainant lodged a complaint with the Consumer Affairs and Fair Business Practices, Cooch Behar. The OP No.1 appeared there and wanted to settle the claim at Rs.23,807/- on 12.09.18. However, the Complainant did not agree and even after a lapse of 4 months, the matter was not settled.
The Complainant also pointed out that in the year 2015, he had undergone gall bladder operation at the same Hospital and made a claim of Rs.38,000/- with the Ops and the Divisional Office, Siliguri settled his claim by paying Rs.27,588/- whereas the Policy value was then Rs.50,000/- each. So, by filing this case, the Complainant claimed for reimbursement of Rs.39,072/-, compensation of Rs.10,000/- for mental pain, agony and harassment and suitable sum as litigation cost.
The Ops contested the case by filing w/v and evidence on affidavit. Apart from usual denial, the Ops in their w/v admitted the claim of the Complainant about the Policy for himself and other members of his family. It is also admitted that the Policy value was enhanced during the year 2016-17. It is the contentions of the Ops that there is a condition precedent that the expenses on treatment of ailments/disease/surgeries, if contracted and/or manifested after inception of first Policy ( subject to continuity being maintained) are not payable during the waiting period and for gall bladder i.e. calculus disease, the waiting period is two years. The date of operation was within two years after the enhancement of insured sum to Rs.1 lakh from Rs.50,000/-. So, all the expenses were calculated proportionately taking the sum insured. So, it is claimed that the Ops are ready to pay the said ascertained amount of Rs.23,807/-. The Ops denied about any deficiency in service or unfair trade practice on their part.
POINTS FOR CONSIDERATION
- Is the Complainant a Consumer as per provision under Section 2(1)(d)(ii) of the C.P. Act, 1986?
- Has this Forum jurisdiction to entertain the instant complaint?
- Is there any deficiency in service and/or unfair trade practices on the part of the Ops as alleged?
- Whether the Complainant is entitled to get any relief/reliefs, as prayed for?
DECISION WITH REASONS
Point No.1 and 2.
On going through the written complaint, w/v, evidence and documents furnished by both sides, and on a careful consideration, we find that that the Complainant is a “consumer” in accordance with the definition of the term as per Consumer Protection Act, 1986.
The residence of the Complainant and Office of the Op are within the jurisdiction of this Forum. Therefore, we find that the cause of action arose within the territorial jurisdiction of this Forum and the claimed amount is also within the pecuniary limit of the District Forum. Thus, these points are disposed of in favour of the Complainant.
Point No.3 and 4.
On consideration of the contentions of both the parties as appeared from the petition of complaint, w/v, evidence on affidavit and written argument, it is found, admittedly, that the Complainant had obtained Policy initially in the year 2009-10. He obtained the Policy for four members of his family namely himself, his wife Smt. Rama Sehanabis,his son and daughter. Initially, the insured value was Rs.50,000/- for each of them and the Policy was renewed every year by the Complainant. Subsequently in the year 2016-17, the assured sum of the Policy was enhanced to Rs.1 lakh from Rs.50,000/- for each of them.
The present dispute arose out of the claim for reimbursement of expenses for gall bladder (calculus disease) operation of the wife of the Complainant which she underwent on 26.04.108 at Dishery Health Point Pvt. Ltd., Malda with prior intimation to the Ops.
The Complainant submitted his claim for reimbursement through the Agent on 11.05.18 and the break-up of such claim are as follows:-
- Cost of operation including Bed, OT Charges etc. - Rs.25,120/-
- Cost of pathological test - Rs. 5,860/-
- Medicine Bill - Rs. 8,092/-
Thus, Rs.39,072/- in total.
As per contentions of the Ops, the Complainant is not entitled to the said amount of his claim and his claim would be limited to the proportionate amount on the basis of his entitled room charge. So, the OP agreed to pay Rs.23,807/- (Annexure-3) comprising Bed Charge of Rs.1,000/-, OT/Investigation/Doctor Charge of Rs.15,270/- and cost of Medicine of Rs.7,537/-On behalf of the Ops, some relevant points in the Policy Bond (Mediclaim Insurance Policy (Individual) of The Oriental Insurance Co. Ltd. (Annexure-10) were brought to our notice.
The entitlement of expenses under each head has been mentioned therein. According to the said Policy Bond under the head “Hospitalisation Benefits”, expenses of Room, Boarding and Nursing expenses as provided by the Hospital/Nursing Home is restricted to not exceeding 1% of the sum insured per day. It has also been mentioned therein that admissibility of all related expenses (c and d) for Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees etc., except for medicine/pharmacy bills and body implants, shall also be as per the entitled category vis-à-vis room rent.
It is further found that Point No.4.3 under head “General Exclusions” provides for waiting period for certain ailment/disease/surgery and the expenses on treatment of those ailments/diseases if contracted and/or manifested after inception of first policy (subject to continuity being maintained) are not payable during the waiting period specified against respective disease.
Calculus disease is included in the said category for which waiting period is shown as two years. There is a “Note” giving explanation and the same is reproduced below with important and relevant portion under Bold letters for convenience of our discussion:
“Note: If the continuity of the renewal is not maintained, then subsequent cover will be treated as fresh policy and clauses 4.1., 4.2, 4.3 shall apply afresh, unless agreed by the Company and suitable endorsement passed on the Policy, by the duly authorized official of the Company. Similarly, if the sum insured is enhanced subsequent to the inception of the first policy, the exclusion 4.1, 4.2 and 4.3 will apply afresh for the enhanced portion of the sum insured.”
The very words “subsequent to the inception of the first policy, the exclusion 4.1, 4.2 and 4.3 will apply afresh for the enhanced portion of the sum insured” seem to be very important and meaningful. As per said Note, the exclusion of reimbursement for enhanced portion will apply if the assured sum is enhanced subsequent to the first Policy.
Here in this case, the Complainant claimed that the Policy was first obtained by him and 3 other members of his family in 2009-10 and since then, he has been renewing the policy year to year and this was not denied by the Ops. The renewals are found to have been continuous and without any break in period from the year 2009-10 to till date. So, the renewal of Policy for the year 2016-17 when the insured amount was enhanced cannot be said to be the first Policy. So, the contentions of the Ops that the reimbursement must be of proportionate amount cannot arise at all. Therefore, argument of the Ops in this regard is not acceptable.
It is found that the Complainant filed papers for reimbursement on 11.05.18 and the same was not processed for a couple of months. Later, Ops wanted to settle the matter by paying Rs.20,000/- against the claim of the Complainant but the Complainant did not agree and ultimately, he had approached Consumer Affairs & Fair Business Practices, Cooch Behar. When the Complainant lodged complaint with the Consumer Affairs & Fair Business Practices, Cooch Behar, the OPs came with the proposal for payment of Rs.23,860/-. In the meantime, there was already delay of 4 months. This delay thus contributes to deficiency in service on the part of the Ops.
It is found that the Complainant claimed Rs.850/- per day for Room rent which is below 1% of the sum insured. So, the Room rent for two days would be Rs.1,700/- For cost of operation including Bed, OT charges etc. was Rs.25,120/-, cost of pathological test was Rs.5,860/- and medicine bill was Rs.8,092/-, total Rs.39,072/-.
It is found from Annexure-3 submitted on behalf of the OP, which contains the calculation of the amount they had agreed to pay towards the claim of the Complainant that besides Rs.1,000/-which was allowed as two days’ room rent, the total amount towards OT and Dressing charges, investigation charges and Doctors’ fees amounting to Rs.25,960/- was allowable though its proportionate amount was actually allowed therein. But, we have already held that the question of proportion does not arise. Thus, the amount of claim which is entitled to by the Complainant comes to Rs.1,700/- for room rent, Rs.25,960/- for OT charges etc., Rs.5,860/- for investigation charges and Rs.7,537/- for medicine, thus Rs. 41,057/- in total. The Complainant is entitled to this amount from the OP.
The entire episode gives an impression that the OP was very much reluctant since the initial stage and wanted to settle the matter by paying much lesser amount, thereby depriving the Complainant, who is a very regular and particular in the matter of renewal of Policy of his legitimate claim. So, the aforesaid conduct of the OP is nothing but amounts to unfair trade practice on their part. So, the Complainant is entitled to Rs.10,000/- as compensation for harassment, mental pain and agony etc. This apart, Complainant is also entitled to Rs. 3,000/ towards litigation cost.
These issues are thus decided infavour of the Complainant.
Hence, it is
Ordered
That the instant case be and the same is allowed on contest with cost.
The Ops are directed to pay Rs.41,057/- to the Complainant towards his claim. This apart, Ops are directed to pay Rs.10,000/- to the Complainant towards deficiency in service and mental pain and agony. Ops are also to pay Rs.3,000/- towards cost of litigation.
If the aforesaid order is not complied within 30 days from the date of this order, the Ops are liable to pay interest @ 6% per annum on the entire awarded sum for a period until realization. Complainant shall also be at liberty to execute the said order in accordance with law.
Let plain copy of this Order be supplied to the parties concerned by hand/by Post forthwith, free of cost for information & necessary action, if any. The copy of the Final Order is also available in the official Website: www.confonet.nic.in.
Dictated and corrected by me.
