Date of filing : 13.9.2018
Judgment : Dt.15.1.2020
Mr. Ayan Sinha, Hon’ble Member
This is a complaint made by Sri Ranjan Moulick residing at 50/D, Chakraberia Road (North), P.S.-Bhawanipur, Calcutta – 700 020 against the Deputy General Manager, the New India Assurance Company Ltd. (Govt. of India), 1st floor, 4, Mango Lane, Kolkata – 700 001 (OP No.1), MD. India Healthcare Service (TPA) Pvt. Ltd., C-483, Lake Gardens, Ground floor, near Lords Bakery Crossing and Khelaghar School, Kolkata-700 026, P.S.-Lake (OP No.2) and Amri Hospital, Dhakuria, a unit of Amri Hospitals Ltd., P 4 & 5, CIT Scheme, LXXII, Block-A, Gariahat Road, Kolkata-700 029 (Proforma party), praying for direction upon the OP No.1 to pay Rs.2,00,000/- to pay 18% interest on the unpaid amount of Rs.2,00,000/- from 20.6.2018 till date along with compensation of Rs.2,00,000/- and litigation cost of Rs.1,00,000/-.
FACTS IN BRIEF
The Complainant being the principal and the proposer of his mother Smt. Radha Rani Moulick, purchased a Health Scheme Policy No.S1010034172500001699 from the OP No.1, for an insured sum of Rs.3,00,000/. The Complainant’s mother suddenly fell ill and was admitted to AMRI Hospital, Dhakuria on 30.1.2018. As stated by the petitioner that his mother was treated at ICCU by eminent and specialized Doctors of AMRI and spent Rs.5,68,103/- for treatment but due to irony of fate his mother died on 10.2.2018 at AMRI, Dhakuria. The Complainant also stated in the petition of complaint that he has been paying the insurance charges for his mediclaim from the year 1998 without any default in payment of premium. But, OP No.1 most arbitrarily and whimsically paid Rs.1,00,000/- against the sum insured policy of Radha Rani Moulick of Rs.3,00,000/-. Thereafter, he wrote a letter dt.27.4.2018 to the Deputy General Manager, The New India Assurance Co. Ltd. (OP No.1) requesting to remit the balance amount of Rs.2,00,000/- to which OP No.1 did not reply. Thereafter, he sent a legal notice through his Ld. Advocate on 20.6.2018 with a copy to OP No.2 to which OP No.1 sent a reply dt.1.8.2018 stating that the Complainant’s mother was suffering from disease which was existed before inception of policy and for which they are not liable to pay the balance of Rs.2,00,000/-. It is also alleged by the Complainant that OP No.1 received the premium every year from the inception of the policy i.e. in the year 1998 without raising any question of pre-existing disease but at the time of reimbursement of the mediclaim, OP No.1 raised the issue of pre-existing disease which is against the policy of the insurance company. OP No.2 who is the TPA of OP No.1 has wrongly scrutinized the medical papers supplied by the petitioner and wrongly advised the insurance company to disburse only Rs.1,00,000/-. OP No.1 miserably failed to discharge their obligations and was negligent and deficient in providing service to the Complainant. Thus being aggrieved the Complainant filed this petition of complaint.
Notices were served upon OP No.1, OP No.2 and the proforma OP. OP No.1 contested this case by filing written version stating inter alia that as per the ‘claim payment statement – Additional Payment claim’ sent to the Complainant by their authorized TPA, Mrs. Radha Moulick was admitted on 30.1.2018 at AMRI Hospital with an intimation on 31.1.2018 and was discharged on 10.2.2018. The Diagnosis was sepsis with multi-organ chronic obstructive airway disease with a sum insured of Rs.1,00,000/- and as per the medical team report of OP No.2, the patient had HTN ASTHMA and so the claim has been settled for Rs.1,00,000/- against the enhanced sum insured of Rs.3,00,000/- as because the enhanced sum insured has not completed 48 months, which is the claim free period for pre-existing disorder. As per their claim policy mentioned under 4.1 mediclaim policy that “Treatment of any pre-existing condition disease, within 48 months of continuous coverage of such insured person have elapsed, from the date of inception of his/her first policy with us as mentioned in the schedule”. Since the enhanced sum insured policy has not completed 48 months, so the complainant cannot demand more and thus prayed for setting aside this case.
OP No.2 did not contest this case by filing written version and the matter was heard ex-parte against them.
The Proforma OP i.e. AMRI Hospital also contested this case by filing written version, stating that Mrs. Radha Moulick aged 71 years was admitted in ICCU of their hospital on 31.1.2018 and died on 10.2.2018 at the hospital. The billed amount was for Rs.5,68,107/- towards the cost of treatment and was deposited by the patient party. Since the Complainant has not alleged for deficiency of service against the hospital, so prayed for deletion of their name from the instant case.
The Complainant has filed affidavit-in-chief to which questionnaires were filed separately by OP No.1 and Proforma OP against which the Complainant has filed affidavit-in-reply. Similarly, OP No.1 filed evidence to which the Complainant has filed questionnaire against which OP No.1 has filed Affidavit-in-reply. On perusal of the records, it appears no evidence has been filed by the proforma OP i.e. AMRI Hospital.
Brief notes of arguments were filed by the Complainants, the OP No.1 and the Proforma OP.
Main points for determination
(i) Whether there is any deficiency on the part of OPs?
(ii Whether the Complainant is entitled to the relief as prayed for?
Decision with reasons
Point No.(i) &(ii) :
Both the points are taken up together for comprehensive discussion and to avoid repetition.
On perusal of the copies of health insurance policies for the year 2014-2015, 2015-2016 and 2017-2018 filed by the Complainant, it appears that the Complainant being the proposer continuing the health insurance policies for himself and his mother from 1998, the copy of the health insurance policy No.51010034142500002058 also transpires that the Complainant has enhanced the sum insured for her mother from one lakh to three lakhs in the year 2014-2015 as mentioned in the said policies under caption “change in status two lakhs” and under caption “date of inception of continuous coverage” mentioned as from 1998. The copy of the health insurance policy No.51070034172500001699 for the year 2017-2018 also indicates that the health policy is continued with an insured amount of Rs.3,00,000/- for his mother who had expired on 10.2.2018 in AMRI Hospital i.e. Proforma OP. The death of his mother is also supported by a copy of KMC Death Certificate. The Complainant has also filed a copy of bill No.DHIPBL/10040924 dt.10.2.2018 for Rs.5,68,103/- (After discount) issued by the Proforma OP AMRI Hospital, wherefrom it reveals that the OP No.2 i.e. TPA of OP No.1 has settled only with Rs.1,00,000/- instead of insured amount of Rs.3,00,000/-. On perusal of the claims payment statement dt.15.3.2018 issued by the OP No.2, it appears that the diagnosis was for Sepsis with multi-organ chronic obstructive AIRWAY disease and thus claim settled at Rs.0 account of the above said disease although the balance sum insured after claim shown as Rs.2,00,000/-. It is clearly stated that they have acted as per instruction of OP No.1. OP No.1 admitted in their written version that they have settled the claim with Rs.1,00,000/- instead of Rs.3,00,000/- since Complainant’s mother had H.T.N. Asthama in past history which is as per the report of the medical team of TPA and so pre-existing disease policy which is in clause 4.1 of the Policy is applicable which states “treatment of any pre-existing condition/disease until 48 months of continuous coverage of such insured persons have elapsed from the date of inception of his/her first policy with us as mentioned in the schedule”.
There is no doubt that the Complainant had enhanced the insured amount from Rs.1,00,000/- to Rs.3,00,000/- in 2014-2015 and the stipulated time for 48 months has not elapsed.
Now main contention is whether the Complainant had pre-existing disease as alleged by the OP No.1.
Significantly, no such documentary proof or expert opinion or medical journal is produced from the sides of OP to satisfy us that there was a pre-existing disease from the date of enhancement of the said policy as averred by the Ld. Advocate for the OP No.1 citing the exclusion clause of 4.1.
During argument, Ld. Advocate for the Complainant has not sought any relief against the Proforma OP. The same is already mentioned in the BNA of Proforma OP also.
In view of this, we are unable to endorse the repudiation of instant claim of Rs.2,00,000/- by the OPs simply showing the reasons for pre-existing disease.
In this matter, we have relied upon the judgment of Hon’ble NCDRC in Tarlok Chand Khanna VS United India Insurance Co. Ltd. on August, 2011, where the mediclaim was repudiated on the ground of pre-existing disease and in the said case Hon’ble National Commission observed – “The onus to prove that petitioner was suffering from a pre-existing disease as per settled law is on the respondent. We note that respondent has not produced any credible documentary evidence/expert medical opinion in support of its case” and so Hon’ble National Commission was pleased to hold that in the absence of any credible documentary or other evidence by the respondent on whom the onus to prove the reasons for repudiation has failed to prove the same. In this case also OPs have not filed any medical expert opinion or other evidence to prove the reasons for repudiation, in other words to justify the repudiation of the claim on the ground of pre-existing disease.
So, we hold there is certainly a deficiency of service upon OPs by repudiating the claim of the Complainant in this instant case. Accordingly, we allow the instant petition of complaint in part and the Complainant is entitled to the reliefs.
As such, point No.(i) & (ii) are answered accordingly.
Complainant being aggrieved has filed this case in September, 2018 with a prayer also for interest payment @ 18% over the unpaid amount of Rs.2,00,000/- along with compensation of Rs.2,00,000/- and litigation cost of Rs.1,00,000/- which in our opinion is exaggerated. So, we are of the opinion, if a direction be given upon OP No.1 & 2 to pay the Complainant the due claim amount of Rs.2,00,000/- along with compensation of Rs.50,000/- and litigation cost of Rs.10,000/- justice would be served.
Hence,
ordered
CC/555/2018 is allowed in part on contest against OP No.1 and ex-parte against OP No.2. OP No.1 and OP No.2 are jointly and severely directed to pay Rs.2,00,000/- along with compensation of Rs.50,000/- and litigation cost of Rs.10,000/- within 45 days from the date of communication of this order, in default the entire amount shall carry interest @ 7% p.a. till realisation.
