Sri Kamal De, President
The case of the complainant, in short, is that the wife of the complainant, Smt. Kalpana Kuity, held a Mediclaim policy under the OP vide policy no. 51260034152500000001 and the policy began from 03.04.2015, 12.01 AM to 02.04.2016, 11.59.59 PM. During the continuance of the policy, the wife of the complainant met with an accident on 03.05.2015 for which she had to suffer L1 Vertebral Collapse which is duly covered under the policy in question. She was taken to Dr. Sandipan Bhattacharyya of Haldia S.D. Hospital (M.S. Ortho) who after initial treatment referred her to a Multispecialty Hospital on 07.05.2015. Accordingly, Smt. Kuity was taken to Apollo Hospital at Chennai and was admitted under Dr. Ravi V (Ortho) DNB, Orthopaedics. On 13.05.2015 she underwent an operation namely L1 Vertebroplasty under Local Anaesthesia. The complainant had to incur an amount to the tune of Rs.104395/- towards paying of hospital bills for the said operation. However, the final claim of the complainant for mediclaim policy of complainant’s wife was Rs.136657/-.
The complainant informed the matter of accident on 04.05.2015 to the OP and submitted the Claim Form vide claim no. HH241601901(R) alongwith all relevant treatment papers and bills and other documents, but till date the OP has not settled the claim. Hence, this case.
The Op in filing W/V has stated that the complainant has filed this case for wrongful gain. The OP has stated that OP on 12.09.2015 vide his repudiation letter informed the complainant that the claim has been denied for the reason “as per policy condition the P.I.D. confirmed as on 03.04.2014 the claim for vertebral collapse cannot be admissible under clause no. 4.3.1 for not continuous 24 months policy. (NIA policy 2012). Hence the claim is hereby rejected.” The OP has prayed for dismissal of the case.
Point for consideration
- Whether the complainant is entitled to get the relief on account of mediclaim?
Decision with reason
We have gone through the materials on record as filed from both the parties. It appears for the documents on record that the complainant availed a mediclaim policy in the name of his wife Smt. Kalpana Kuity alongwith her son and daughter under TPA namely Heritage health TPA Pvt. Ltd., Kolkata commencing from 03.04.2015 to 02.04.2016. In the instant case the sum insured for the victim is Rs.150000/- and for son and daughter Rs.100000/- each. From the Discharge summary it appears that Smt. Kalpana Kuity suffered L1 Vertebral Collapse and she underwent surgery of L1 Vertebroplasty under Local Anaesthesia at Apollo Hospital at Chennai. From the policy itself it appears that the date of inception of continuous coverage is from 03.04.2014. Subsequently, the complainant also filed Xerox copy of document to show that Smt. Kalpana Kuity also obtained policy in 2012 from Heritage Health TPA Pvt. Ltd. So it is apparent that she has been holding policy for continuous period of more than 24 months. The claim of the insured as we find was repudiated as the claim for vertebral collapse cannot be admissible for not continuous for 24 months policy but we find that there is a condition “unless arising from accident” (Clause 4.3.1 of the terms and condition of Mediclaim 2012 policy document referred to). It is stated that in the petition of complaint that the wife of the complainant met with an accident on 03.05.2015 for which she had to suffer L1 Vertebral collapse which is duly covered under the said policy. It also appears that the patient was firstly taken to Haldia S.D. Hospital and thereafter she was taken to Apollo Hospital at Chennai being referred from Haldia S.D. Hospital. We think that the rejection of claim is illegal and amounts to deficiency of service. The fact of meeting with accident by Smt. Kalpana Kuity has not been contradicted from the side of the OP in W/V or WNA. Clause 4.3.1 of Terms and condition of the Policy document as such is not attracted. We think that the complainant is entitled to get the amount of Rs.136657/- for Hospital bills, medicines, Doctor checkups etc. as claimed apart from compensation for mental agony and harassment.
Hence,
ORDERED
that the instant case being no. CC/35/2016 be and the same is allowed on contest. OP is directed to pay an amount of Rs.136657/- alongwith Rs.20000/- as compensation and Rs.5000/- for litigation cost within 40 days from this date of passing the order i.d. the complainant will be at liberty to put the order into execution and in the event the OP will be liable to pay interest @ 9% per annum on the total amount till full and final payment.
