Date of Filing: 18.04.2019. Date of Disposal: 08.12.2022.
Complainant :Sri Amlan Kusum Trevidi, S/o Sri Aditya Kumar Trivedi R/o Upadhyay Para, Near Shiv Mandir, Panchgachiya, P.O. Ethora – 713359, P.S. Asansol (North).
-VERSUS -
Opposite Party :1.The Chief Executive Officer /Director, STAR HEALTH & ALLIED INSURANCE CO. LTD. at Regd/Corp Office-1, New Tank Streetm Balluvar Cotton, High Road, NUNGAM BAKKAM, Chennai – 600034.
2. The Executive Officer, Star Health & Allied Insurance Co. Ltd., No.116, G.T. Road, 2nd Floor, Near Vijaya Bank, Asansol, P.O. Asansol, P.S. Asansol(S), Dist.- Paschim Bardhaman (W.B.) Pin-713303.
3. The Superintendent. H.L.G. Hospital, Sen Releigh Road, Asansol, Dist. Paschim Burdwan, (W.B.) -713305.
Present : Mohammad Muizzuddeen -Hon’ble President.
: Mrs. Lipika Ghosh - Hon’ble Member.
: Mr. Atanu Kr. Dutta. - Hon’ble Member.
Appeared for the Complainant : Mr. Pradeep Kumar Sinha Ld. Advocate.
Appeared for the Opposite Party : Mr. Niraj Kumar Singh -Ld. Advocate (for OP Nos.
1 & 2).
: Mr. Biswajit Narayan Chowdhury - Ld. Advocate
(for OP No.3).
FINAL ORDER
On 18.04.2019 the complainant, Amlan Kusum Trivedi lodged this complaint u/S 12 of the Consumer Protection Act, 1986, against the OPs.
The case of the complainant, in brief, is that the complainant purchased two health policies for the period of 26.08.2017 to 25.08.2018, coverage of Rs. 3,00,000/- from the OP No.1 and 2. On 03.01.2018, the complainant fell ill and being suffered of Pneumonia and cold and admitted as H.L.G. Hospital, Sen Releigh Road, Asansol, Dist. Paschim Bardhaman, wherein he was medically treated and was discharged on 07.01.2018. The said Hospital was enlisted under the insurance company for cashless medical treatment. On 03.01.2018 Mr. Ankur Das Gupta, an agent of the OPs, who sold the Policies in question came to H.L.G. Hospital and completed the entire formalities of cashless medical treatment. But on 04.01.2018, some officials of the OPs came from Bolpur Branch of OPs Insurance Office and changed the Cashless Medical Treatment schedule of the policies in question and made the same into reimbursement scheme. The complainant was surprised. However the complainant paid the medical treatment bill of Rs. 38,000/- to the said hospital and later on he made the claim for reimbursement for the said amount before the OP but it was rejected with a plea that the said complainant did not disclose his previous medical treatment report i.e. prescription, diagnosis report etc. The complainant on various times requested the OP through Email, telephonic talk but no response was made from the OP. It is also stated that before Jan 2018, he had no any disease like cold cough, pneumonia, so how could he has disclosed such type of medical report. The complainant then issued an Advocate Notice to the OP for the payment of said medical bill amount on 09.07.2018. On 27.07.2018 the OP replied with logic that the policy holder did not disclose his previous medical report at the time of purchasing this health policy, hence he is not entitled to get reimbursement of medical benefit of the medical treatment. In this way the OPs have deprived the complainant to get the benefit of cashless medical treatment and committed deficiency in service and unfair trade practice.
Upon this background, the complainant claimed medical treatment bill of Rs. 38,000/- , interest thereof Rs. 1500/- and compensation and damage Rs. 25,000/-.
OP Nos. 1, 2 & 3 have contested the case by filing two separate written versions denying all the material allegations contending inter alia that the complainant has no cause of action for the case and that does not maintainable and that the complainant did not come with clean hand.
The specific case of the OP Nos. 1 & 2 is that it is a general practice within the medical parlance that the line of treatment depends upon sharing of past medical symptom/medical history of the patient, the complainant herein with his treating doctor. In the present case, admittedly the complainant was not a minor and as such he shared her own past medical history with a treating doctor at the said Hospital and Research Centre about the fact that he was suffering from “K/C/O of Long Standing COPD”, which clearly appears to have been deliberately concealed by the proposer/insured patient at the time of filing proposal form. Hence alleged claim is frivolous, vexatious and devoid of merits on the face of it, and the same is liable to be dismissed with heavy costs. That the present complaint is even otherwise not maintainable against the OPs as the complainant has not shown any deficiency in service or arbitrary and illegal repudiation of medi-claim insurance of the complainant, on the part of the OP by placing any evidence on record. The complainant has falsely claimed to have made representations before the answering respondent. The complainant has not placed any evidence of letters, copies of Email or dates of call made to the OPs except serving a notice dt. 09.07.2018, which was duly acknowledged and replied by the OPs vide a letter dt. 27.07.2018. The OPs had raised query letters dt. 03.02.2018, which was responded by the complainant vide a reply dt. 12.02.2018, with undated doctor’s certificate. The OPs subsequently was constrained to repudiate the claim of the complainant vide its letter dt. 19.02.2018, which was duly served upon the complainant and as such the complainant at all material times was aware of the query letter and subsequent rejection by the OP. Hence it is apparent that the complainant has filed this complaint vexatiously and frivolously for the sole purpose of harassing the OPs with the intension for getting unlawful enrichment of the OP, who are dealing with public money and functioning under the guidelines of IRDA controlled by the Government of India.
Upon this background the OP Nos. 1 & 2 prayed for dismissal of the case.
Specific case of the OP No.3 is that the complainant was admitted under OP No.3 by one Manoranjan Upadhyay with a complaint of Chest pain since 5 p.m. on 03.01.2018. He had then COPD also and after examination in emergency at 7.55 p.m. he was admitted in said Hospital under Doctor Subhadeep Ghosh and on 07.01.2018, he was normally discharged from the hospital and all the relevant documents regarding investigation and medical treatment were provided to him at the time of discharge.
The complainant produced his medical insurance card of the OP No.1 bearing customer ID No. 5699117-1 under health policies. Then the OP No.3 informed the Insurance Company with necessary other information by Email but no sanction was received from the end of the OPs (OP Nos. 1 & 2). At the time of discharged on 07.01.2018 this OP No.3 received the sum of Rs. 35,994/- including Pharmacy bill and issued him proper Bill and receipt which was paid by the complainant willingly. He further stated that if any claim of the complainant may stand legitimate, the OP Nos. 1 & 2 will stand liable to pay the same to the complainant.
Upon this background he prayed for discharge him from this case.
Decision with Reasons.
The complainant has filed evidence-on-affidavit.
The W/V supported by an affidavit filed by the OP Nos. 1 & 2 has been treated as their evidence-on-affidavit. OP Nos. 1 & 2 filed questionnaire and OP No.3 also filed questionnaire and the complainant has filed replies to the questionnaires of them. But the complainant did not file any questionnaire to the evidences of the OP Nos.1 & 2. Complainant also filed Written Notes of Argument.
On perusal of the evidence on record of both sides, it is found that the complainant purchased the Health Policies being No. P/191129/01/2018/000515 as it appears from the Xerox copy of the Policy issued by Star Health and Allied Insurance Co. Ltd., and period of insurance was from 26.08.2017 to 25.08.2018, limit of coverage is Rs. 3,75,000/-. The discharged certificate issued by OP No.3 proved that the complainant was medically treated there after getting admission and final diagnosis was made by the OP No.3 as Pneumonia and the OP No.3 also had given the receipt of medical expenditure and the complainant expended near about Rs. 38,000/- whereas the OP No.3 in his W/V stated that they received only Rs. 35,994/- from the complainant and all documents connected to this case have been provided to the complainant. Not a single scrap of paper is available on behalf of the complainant that he was allowed to get the cashless medical treatment benefit. The policy certificate also does not disclose it.
Apart from it, Mr. Ankur Das Gupta, who was an agent of OPs and who sold the Policies to the complainant, also came to the OP No.3 (H.L.G. Hospital), and completed the entire formalities of “Cashless Medical Treatment” either has not supported by any paper
in this case or has not been made party to this case by the complainant and the statement of the complainant that on 04.01.2018 some officials of the OP came from Bolpur Branch of the insurance office and changed the cashless medical treatment schedule into reimbursement scheme has not been supported by any papers or documents even the said Bolpur Branch Office has not been made party to this case by the complainant. According to this fact all the evidence of the complainant is hardly to be believable. Even the complainant did not produce any proposal form containing the pre-history of the patient.
OP No.3 did not adduce any evidence in support of his case, mere filing W/V cannot be treated as evidence and the case of the OP No.3 as stated in his W/V has not been proved unless and until the same be adduced as evidence. Therefore, the W/V cannot be treated as evidence-on-affidavit on behalf of OP No.3.
On scrutiny of submitted medical documents, it is observed that the insured patient is a K/C/O COPD and the duration of the ailment is difficult to ascertain in cashless level and they have rejected the cashless authorization which was communicated to the complainant on 05.01.2018 and subsequently the insured submitted a claim for reimbursement for the expenses incurred for the treatment. On scrutiny of the medical documents, it was observed from indoor case records of above hospital (OP No.3), the insured patient is a known case of COPD and also medical records and investigating reports show long standing COPD. And they requested the complainant to submit the documents which are mandatory to process the claim vide letter dt. 03.02.2018. It is also the evidence of the OP Nos. 1 & 2 that letter from the treating doctor stating the duration of COPD, all the consultation papers/prescription for the past one year and investigation report pertaining to that with previous history of hospitalization with treatment details were asked to be produced. And in the absence of those query and documents which are mandatory, the OPs were unable to process the claim. But the complainant has failed to produce those documents before the OP Nos. 1 & 2.
In the case of Suraj Mal Ram Niwas Oil Mills (P) Ltd. v. United India Insurance Co. Ltd. (2010) 10 SCC 567 the Hon’ble Supreme Court held the interpretation of Insurance Contract:
“That in the same case, i.e. Suraj Mal Ram Niwas Oil Mills (P) Ltd. v. United India Insurance Co. Ltd., (2010) 10 SCC 567, the Hon’ble Supreme Court further held interpretation of insurance contract and its terms – Strict construction prescribed – Words in an insurance contract, held, must be given paramount importance and interpreted as expressed without any addition, deletion or substitution, (2010) 10 SCC 567-C.”
It is clearly stated in the policy schedule that the insurance under this Policy is subject to conditions, clause, warranties, exclusions etc. attached. Accordingly the OP rejected the claim by invoking the conditions vide letter dt. 19.02.2018. Therefore, it can be said that it was the duty of the complainant to produce the said documents before the OP Nos. 1 & 2. The Ld. Advocate for the OPs in his written notes of argument noted down that the Hon’ble Supreme Court in Civil Appeal No. 1130/2007 dt. 22/08/2016 of M/s. Industrial Promotion & Investment Corporation of Orissa Ltd. V. New India Assurance Company Ltd. & Anr, Held : “It is well-settled law that there is no difference between a contract of insurance and any other contract, and that it should be construed strictly without adding or deleting anything from the terms thereof.”
In the instant case, the said Principle of Law as laid down by the Hon’ble Supreme Court, is applicable for the parties of the case.
Under the above facts and circumstances, we are of opinion that the complainant has miserably failed to prove his case to the hilt that the OP Nos. 1 & 2 committed deficiency in service and negligence.
The OP No.3 has no liability according to the case of the complainant.
As a result the case fails.
Hence, it is
ORDERED
that this case be and the same is dismissed on contest against all the OPs, without any cost.
Let a copy of this order be given to the parties on free of cost.
Dictated & corrected by me.
President
D.C.D.R.C , Purba Bardhaman.
Member President
D.C.D.R.C , Purba Bardhaman. D.C.D.R.C , Purba Bardhaman.
