By : SMT. BANDANA ROY, PRESIDENT

         The case of the complainant in short is that he took a mediclaim insurance policy  popularly known as “Heard Guard – Family Floater Option” for his family members  being policy No. OG -14-2422-6001-00000027 from 18.01.14 to 17.01.15 on the sum assured Rs. 2,00,000 by payment of premiums of Rs 6,455/- early for hospitalization.  The said policy is renewed year by year till now.  The complainant felt ill on 04.06.16 and she was treated by Dr. DP Dolai and was referred  and  was admitted at CMRI Calcutta for her treatment from 04.06.16 to 10.06.16  for which she had to expend a sum  of Rs.  48,427/- and allied expenses of Rs. 10,860/-. According to said policy the husband of the complainant demanded the said money by filing all relevant documents for which the OP opened a claim docket No. OC -17-1002-841700002810 against the policy.  But by a letter received by the claimants in the month of November 2016 the OP has repudiated the claim which is illegal and defamatory one .

        Thus, the claimant has filed this case praying for the reliefs for the deficiency of service on the part of the OP.

       The OP appeared and contested the case by filing written version .They contended inter alia that the present case is not maintainable as no repudiation letter has been filed by the complainant. It is further contention of the OP that the present policy is not covered for the disease of the policy holder family.

        The OP has prayed for dismissal of the case on the above grounds.

        The only point for discussion in the case is whether the complainant is entitled to get the reliefs as prayed for.

Decision with Reasons.

          We have perused the complaint, the written version and the documents filed by both the parties in the case.

       Admittedly the complainant’s husband took a  Mediclaim Insurance  policy popularly known as “Heard Guard – Family Floater Option” for his family members namely Samiran Adhikari Sampa Adhikary , Sonali Adhikary and Shrena Adhikari who are the husband and daughters of the complainant  being policy No. OG -14-2422-6001-00000027 from 18.01.14 to 17.01.15 on the sum assured Rs. 2,00,000 by payment of premiums of Rs 6,455/- early for hospitalization.  Admittedly the medi claim insurance policy had been renewing year to year till now. Admittedly the complainant is a beneficiary of the said insurance policy along with her husband and daughters. Admittedly the complainant filed the claim before the OP after she being treated at CMRI Kolkata for her treatment from 04.06.16 to 10.06.16 for “Lower respiration Tract Infection generalized anxiety disorder with somatoform disorder Hemangioioma Liver”and she spent Rs 48427/- for the treatment and had to incur another amount of Rs. 10,860/- as per the complaint. The complainant submitted the claim before the OP  but the OP repudiated said policy in November 2016 .According to the OP  the policy is Health Guard Family Floater option policy  and such  type of disease is not covered by that policy. The OP also stated that they have issued a separate Health  & Wellness card to the policy holders and also his family members for cashless treatments ion Network Hospitals which is subject to the terms and conditions of the policy. But the policy holder did not produce said Health & Wellness Card before hospitalization for cash less treatment.

    Ld lawyer for the OP  showed the terms and conditions  of the policy ., It appears from the record that the Op has produced a copy of Health & Wellness card which they have allegedly issued to the policy holders for having cashless treatment in Network Hospitals. It appears from the Hospital Discharge Summary which has been marked as Annexure III  in the case that the diagnosis of the complainant was GERD Lower Respiratory Track Infection, generalized anxiety  disorder with somatoform disorder Hemangioioma Liver” The OP’s only excuse is that the policy conditions of such type of disease is not covered by this policy. Hence, they repudiated the claim of the complainant.

        Ld. Lawyer for the complainant referred to a decision reported in 2014 (3) CPR 401 (NC) wherein it has been held  that onus of proving the grounds for repudiation of insurance claim lies heavily on the Insurance Co. Ld  lawyer for the complainant also referred another decision reported ion 2016(4) CPR 4 (NC) wherein it has been held that  terms and conditions of Insurance policy must be supplied in writing to the insured.

       We have considered the rival contentions of the parties  and perused the record. Undisputedly the OP repudiated the claim of the complainant.  the OP has failed to substantiate that the disease suffered by the complainant was not covered by the policy. When complainant admittedly is paying the premiums she is entitled to  get the claim from the OP.

         Hence, it is

ORDERED

              That the complainant case No. 308/16 be and the same is allowed on contest against the Opposite Party.

           The OP is directed to pay Rs. 48,427/- with  interest @ of Rs. 9% per annum from the date of filing of this complaint case till actual realization. The OP is also directed to pay compensation of Rs. 10,000/- along with  litigation cost of Rs. 5000/- to the complainant within one month from the date of this order failing which the OP will  have to pay a sum of Rs. 100/- per day as punitive charge which will be payable  to the Consumer Welfare Fund of this Forum.

            Let copy of the judgment be supplied to all the parties free of costs.