Dated : 18 Apr 2023

 HON’BLE SUDIP NIYOGI      PRESIDENT

                                                                                                     FACTS

            The complaint case in short is that: -

            The Complainant obtained one Health Insurance Policy from the OP being Policy No.11971134, Plan Name – Care (IndusInd Bank), Cover Type – Individual, policy period from 21.01.2018 to 21.01.2021 having sum assured of Rs.5,00,000/-  and Member ID No.58647202. It was a single premium policy and Complainant paid the premium through State Bank of India, New Ballygunge Branch, Kolkata – 700039.

On 23.04.2020 Complainant was admitted to Peerless Hospitex Hospital and Research Centre Limited, 360, Panchasayar, Kolkata – 700094 with a history of domestic fall and was diagnosed Tuber Spine Collapse and paraplegia and had been treated under Dr. Prasad Krishnan and was discharged on 06.05.2020. The amount of hospitalization expenses was Rs.3,74,118/- including the pharmacy bill of Rs.57,130.62/-. Thereafter, Complainant submitted a claim for the said amount with all necessary papers with the OP which was duly acknowledged by them. On 06.10.2020, she was informed by the OP that her said Insurance Policy was cancelled. On a query by the Complainant on 21.10.2020 as to the reason for cancellation of her policy through e-mail dated 24.10.2020 she was informed that due to non-disclosure of her pre-existing ailments of schizophrenia, her policy was cancelled and she was not entitled to any claim. Thereafter, Complainant informed the OP by an e-mail on 31.10.2020 that her said illness of schizophrenia was diagnosed by Dr. Prabir Paul on 05.12.2019, which was almost two years after the policy was taken. She further wanted to know under what terms and conditions her policy was cancelled. But OP did not give any reply to her. Thereafter, Complainant served a legal notice dated 24.03.2021 through her lawyer requiring the OP to pay her valid claim within seven days, otherwise, she would take legal action. Despite receipt of the notice, OP failed and neglected to comply with the requirement of the notice.

Finding no other alternative, Complainant filed the instant complaint making an allegation of unfair trade practice and deficiency in service on the part of the OP and claiming several relief(s) in the form of a direction upon the OP to pay her the amount of claimed compensation and cost of litigation.

OP contested this case by filing a written version and adducing evidence. They did not deny the Insurance Policy taken by the Complainant from them. But their only ground is that there was non-disclosure of material information by the Complainant at the time of obtaining the policy. So they cancelled the policy and refused to make payment of her claim and OP prayed for dismissal of the said complaint.

POINT FOR CONSIDERATION

1. Whether the Complainant is entitled to get compensation as prayed for?

                                                                                      FINDINGS

Both parties filed their evidence on affidavit. They also exchanged questionnaires and replies and also filed written argument. Both parties also filed several documents as Annexures.

Admittedly, the Complainant had taken Insurance Policy from the OP and Policy No is 11971134 while the sum assured was Rs.5,00,000/- and Member ID No.58647202. OP issued the said policy on verifying all the documents of the Complainant. It is found from the evidence and also from the documents that Complainant had been admitted to Peerless Hospitex Hospital, Kolkata on 23.04.2020, after she suffered injury which was diagnosed Tuber Spine with D7 Collapse and paraplegia. She was discharged from the hospital on 06.05.2020. It is further found she paid in total Rs.3,74,118/- to the said hospital for her treatment.

Complainant is found to have submitted copies of two certificates for the period from 21.01.2018 to 20.01.2019 and 21.01.2019 to 20.01.2021 which revealed that she renewed her policy with the OP. So, the period of her treatment at the Peerless Hospitex Hospital is found to be during the validity period of her policy.

It is also admitted fact that after discharge from the said hospital, Complainant submitted a claim for Rs.3,74,118/- including pharmacy bill with the OP for realization. But her said claim was refused by the OP on the ground of non-disclosure of material facts at the time of obtaining the Insurance Policy.

According to OP, Complainant had been suffering from schizophrenia and that matter was concealed by her at the time of taking the policy and they could detect the same during investigation after the claim was submitted. As regards this contention, Complainant claimed the said ailment of schizophrenia occurred after about two years of obtaining the policy and it was diagnosed by Dr. Prabir Paul on 05.12.2019, while the policy was renewed in the year 2018. Complainant produced the copy of the medical papers i.e. prescription issued by Dr. Prabir Paul on 05.12.2019 showing that several medicines were prescribed to her.

Apart from this, the discharge certificate of the Complainant issued by the said Peerless Hospitex Hospital and Research Centre Limited showing the date of admission being 23.04.2020 and date of discharge 06.05.2020, reveals in the history that said Madhumita Sinha.ie. Complainant is a known case of schizophrenia for six months. If the said six months is calculated backward from the date of admission which is 23.04.2020, it would be definitely long after the date of 21.01.2019, when her policy with the OP was renewed.

OP failed to produce any sort of cogent documents whatsoever showing that the Complainant had been suffering from the said disease of schizophrenia prior to obtaining her policy and suppressed the same. That being so, it is not understood as to how the OP could claim that there was suppression or non-disclosure of material information as to the health issues of the Complainant. So, the act of the OP in refusing the claim of the Complainant and cancelling her policy is nothing, but unfair trade practice and also deficiency in service on their part.

Therefore, Complainant is entitled to get the realization of her amount she had to spend at the said hospital in connection with her treatment. She is entitled to Rs.3,74,118/- along with interest @ 10% p.a. from the date of repudiation of her claim which is 06.10.2020. This apart, Complainant is also entitled to get Rs.5,000/- for cost of litigation.

Accordingly it is

                                                                            ORDERED

That the instant case be and the same is allowed on contest against the OP.

OP is directed to pay the said amount of Rs.3,74,118/- (Rupees Three Lakh Seventy-Four Thousand One Hundred Eighteen Paise Only) to the Complainant along with interest @ 10% p.a. from the date of repudiation of her claim which is 06.10.2020.

OP is also to pay Rs.5,000/- (Rupees Five Thousand Only) towards cost of litigation, to the Complainant.

OP is directed to comply with this order within 30 days from the date of this order, failing which the awarded sum shall carry interest @12% p.a. until realization in full and Complainant shall be at liberty to realize the same in accordance with law.

Dictated and corrected by me