P.S. Park Street, Kolkata-29.

3)  The General Manager,

           National Insurance Co. Ltd.

           3, Middleton Street,

           P.S. Park Street, Kolkata-71.                                                                                        -------- Opposite Parties

Present :           Sri Sankar Nath Das, President.

                        Smt.  Samiksha Bhattacharya, Member

Order No.   19    Dated  17-07-2013.

          The case of the complainant in short is that the complainant in order to cover up the health of his own and his wife, has purchased a mediclaim policy commonly known as ‘Hospitalization & Domiciliary Hospitalization Benefit Policy’ bearing policy no.100100/48/06/8500002038 jointly with his wife Smt. Naseem Ahmad for Rs.5 lakhs with a yearly premium of Rs.21,534/- with the National Insurance Co. Ltd. i.e  o.p. no.1.

            Complainant states that from the very inception of taking the policy i.e. from 27.2.01 the complainant has been paying regularly the yearly premium as stipulated in connection with the said policy without any break or interruption and also renewing the same from time to time in accordance with the rules.

            Complainant has suddenly felt severe chest pain and become ill on 30.1.08 and immediately consulted Dr. Subrata Moitra who has referred to Dr. Sunip Banerjee, a specialist doctor of R.N. Tagore International Institute of Cardiac Sciences.

            Complainant further states that as per advice of Dr. S. Moitra, he has consulted Dr. Sunip Banerjee who has examined the complainant very carefully and admitted him to R. N. Tagore International Institute of Cardiac Sciences located at Mukundapur, Kolkata-99 on 5.2.08 and confined him till 6.2.08 for medical investigation and tests.  On investigation, his disease has been arrested and diagnosed by the said doctor Dr. Sunip Bnaerjee as ‘Triple Vessel Coronary Artery presented with unstable angina’ and Dr. Banerjee has prescribed some medicines for his treatment and referred to an eminent surgeon Dr. Kunal Sarkar.  

            For better treatment and speedy recovery, the complainant as per advice of Dr. Sunip Banerjee, has consulted Dr. Kunal Sakar who has further examined the complainant thoroughly and after going through the medical examination and test reports, has advised him to undergo a surgical intervention namely ‘Coronary Artery Bypass Grafting’.

            Complainants as per advice of Dr. Sarkar, was admitted to R.N. Tagore International Institute of Cardiac Sciences on 22.2.08, operated under the supervision of Dr. Kunal Sarkar on 26.2.08 and after the post-operation treatment, he was duly discharged on 8.3.08.

            Complainant further states that for his medical treatment, the complainant has incurred a total expenditure of Rs.2,17,850/- towards the consultation fees, surgeon’s fees, operation charges, bed charges, cost of medicines, oxygen, blood, medical examination charges, etc. for the re-imbursement of which he has submitted his ‘claim form’ with the o.p. no.2.

            Complainant submits that he has lodged his claim with o.p. no.2 demanding Rs.2,17,850/- towards the reimbursement of the aforesaid medical expenditure along with all necessary papers, bills documents, etc. as required by the o.ps. within the stipulated period on 24.3.08, but unfortunately his genuine claim of Rs.2,17,850/- has been repudiated by the o.ps. on the pretext of –pre-existing disease’, which is absolutely untrue, baseless, arbitrary and also contrary to the rules and regulations of the insurance policy.

            Complainant further submits that despite his repeated requests, personal approach and a series of written representations on various dates for settlement of his genuine claim, o.ps. have not paid any heed, rather tried to avoid the matter of reimbursement on one pretext or another.

Hence the case was filed by the complainant with the prayer contained in the petition of complaint.

            O.p. nos.1 and 3 had entered their appearance in this case by filing w/v and denied all the material allegations labeled against them and prayed for dismissal of the case. Ld. lawyer of o.ps. in the course of argument submitted that the case has got no merit and the same is liable to be dismissed. O.p. no.2 did not contest the case by filing w/v and matter was heard ex parte against o.p. no.2.

Decision with reasons:

            We have gone through the pleadings of the parties, evidence and documents in particular and we find that complainant in order to cover up the health of his own and his wife, has purchased a mediclaim policy commonly known as ‘Hospitalization & Domiciliary Hospitalization Benefit Policy’ bearing policy no.100100/48/06/8500002038 jointly with his wife Smt. Naseem Ahmad for Rs.5 lakhs with a yearly premium of Rs.21,534/- with the National Insurance Co. Ltd. i.e  o.p. no.1.

            We further find that from the very inception of taking the policy i.e. from 27.2.01 the complainant has been paying regularly the yearly premium as stipulated in connection with the said policy without any break or interruption and also renewing the same from time to time in accordance with the rules.

            It is seen from the record that complainant has suddenly felt severe chest pain and become ill on 30.1.08 and immediately consulted Dr. Subrata Moitra who has referred to Dr. Sunip Banerjee, a specialist doctor of R.N. Tagore International Institute of Cardiac Sciences.

            It is also seen that as per advice of Dr. S. Moitra, he has consulted Dr. Sunip Banerjee who has examined the complainant very carefully and admitted him to R. N. Tagore nternational Institute of Cardiac Sciences located at Mukundapur, Kolkata-99 on 5.2.08 and confined him till 6.2.08 for medical investigation and tests.  On investigation, his disease has been arrested and diagnosed by the said doctor Dr. Sunip Bnaerjee as ‘Triple Vessel Coronary Artery presented with unstable angina’ and Dr. Banerjee has prescribed some medicines for his treatment and referred to an eminent surgeon Dr. Kunal Sarkar. 

            It transpires from the record that for better treatment and speedy recovery, the complainant as per advice of Dr. Sunip Banerjee, has consulted Dr. Kunal Sakar who has further examined the complainant thoroughly and after going through the medical examination and test reports, has advised him to undergo a surgical intervention namely ‘Coronary Artery Bypass Grafting’.

            It also transpires that complainant per advice of Dr. Sarkar, was admitted to R.N. Tagore International Institute of Cardiac Sciences on 22.2.08, operated under the supervision of Dr. Kunal Sarkar on 26.2.08 and after the post-operation treatment, he was duly discharged on 8.3.08.

            From the record we find that for his medical treatment, the complainant has incurred a total expenditure of Rs.2,17,850/- towards the consultation fees, surgeon’s fees, operation charges, bed charges, cost of medicines, oxygen, blood, medical examination charges, etc. for the re-imbursement of which he has submitted his ‘claim form’ with the o.p. no.2.

            And complainant has lodged his claim with o.p. no.2 demanding Rs.2,17,850/- towards the reimbursement of the aforesaid medical expenditure along with all necessary papers, bills documents, etc. as required by the o.ps. within the stipulated period on 24.3.08, but unfortunately his genuine claim of Rs.2,17,850/- has been repudiated by the o.ps. on the pretext of ‘pre-existing disease’, which is absolutely untrue, baseless, arbitrary and also contrary to the rules and regulations of the insurance policy.

            In view of the findings above and on perusal of the entire materials on record we find that the repudiation of the claim of the complainant is not justified while at the relevant point of time complainant had valid insurance policy coverage. It is not supposed to know by common people that what sorts of disease he is carrying. It is not the case of o.ps. that complainant was a defaulter in the matter of making payment of premium policy. Simply on the ground of violation of the clause of insurance policy o.ps. should not repudiate the justified claim of the complainant. Hon’ble Supreme Court of India expressed views published in CTJ May 2010 Vol-18 No.5 Page 66 that insurance company is bound to pay some portion of the claim whilst complainant has valid insurance policy.

            In view of the findings above and having due regard to the decision of the Hon’ble Apex Court we are of the views that complainant is entitled to relief in part and o.ps. had sufficient deficiency being service provider to their consumer / complainant.

            Hence, ordered,

            That the case is allowed on contest with cost against o.p. nos.1 and 3 and ex parte without cost against o.p. no.2. O.p. nos.1 and 3 are jointly and/or severally directed to pay to the complainant a sum of Rs.1,50,000/- (Rupees one lakh fifty thousand) only towards claim of the complainant (non standard basis) and are further directed to pay compensation of Rs.30,000/- (Rupees thirty thousand) only for harassment and mental agony and litigation cost of Rs.5000/- (Rupees five thousand) only within 45 days from the date of communication of this order, i.d. an interest @ 10% p.a. shall accrue over the entire sum due to the credit of the complainant till full realization.

                        Supply certified copy of this order to the parties free of cost.