Final Order/Judgment
Debasis Bhattacharya:- PRESIDING MEMBER
Being aggrieved by and dissatisfied with the service extended by National Insurance Company Ltd. (hereinafter referred to as OP) of the address as mentioned above, in the matter of lodging of a claim of reimbursement of medical expenses related to the medical treatment and surgery of his son and subsequent repudiation of the said claim by the insurance company, the instant case has been filed by the complainant, u/s 12 of the Consumer Protection Act 1986.
The fact of the case is as follows.
The complainant, being a holder of the medical Insurance Policy bearing No. 153600501810003387 of the OP since 31.07.2005, preferred a claim on 04.01.2019 for reimbursement of the medical expenses arising out of the medical treatment including surgery of his son, on the strength of the said policy. However, reportedly the disposal of the claim was kept pending for almost seven months and the complainant was compelled to send a legal notice to the OP on 25.07.2019. On receipt of the said notice the OP in their communication dtd.02.08.2019 repudiated the claim stating that ‘The claim is not admissible as it is congenital external disease’. Apart from this, the OP through an Advocate’s letter also informed that the claim was rejected / repudiated as it was excluded under clause 4.3 of the terms and conditions of the insurance policy.
The complainant claims to have suffered immense mental agony and being a middleclass person he had to arrange the required finance to meet the medical expenses by some other difficult means.
Considering the stance taken by the OP, as deficiency of service and illegal trade practice, the complainant submits a prayer before this Commission to impose direction upon the OP to reimburse the claim to the extent of Rs.2,00,000/- i.e the amount covered by the policy, Rs.5,00,000/- for sufferings and mental agony and to pass any other order or orders as the Commission may deem fit and necessary to meet the ends of justice.
In view of the above discussion and on examination of available records it transpires that the complainant is a consumer as far as the provisions laid down under Section 2(1)(d)(ii) of the Consumer Protection Act 1986 are concerned.
Both the complainant and the opposite party are resident/having their office address within the district of Hooghly.
The claim preferred by the complainant does not exceed the limit of Rs.20,00,000/-.
Thus, this Commission has territorial as well as pecuniary jurisdiction to proceed in the instant case.
The issues related to the questions whether there was any deficiency of service and whether the complainant is entitled to get any relief, being mutually inter-related, are taken together for convenient disposal.
The complainant, to establish his point, has filed copies of the policy papers, claim form, medical documents, viz. first Visit Report, discharge summary, final medical bill, lawyer’s notice sent to the OP and postal acknowledge receipt thereof, OP’s letter repudiating the claim, communication of the lawyer of the OP, questionnaire sent to the concerned Medical practitioner through e-mail and replies received through e-mail thereof.
The OP has contested the case by filing written version, evidence on affidavit and brief note of argument.
Materials on records are perused.
The policy being a floater one, covered the entire family of the complainant consisting of his wife, his son and he himself. The policy was valid during the material period.
As it is stated, the complainant’s son has been suffering from Internal Congenital Disorder and had to undergo a surgery in a nursing home under the name “Park Clinic’. Admission of the patient was on 26.11 2018 and discharge was on 12.12.2018. TPA of the Insurance Company was duly informed and Claim form was duly submitted on 04.01.2019 along with all relevant documents. On 02.08.19 i.e almost after seven months the OP repudiated the claim assigning the reason as stated before in this order.
Now the OP in their written version, evidence on affidavit and brief notes of argument repeatedly refers to clause 4.3 of the terms and conditions annexed to the policy documents. The OP claims that the particular medical treatment i.e. treatment for internal congenital disorder for which reimbursement expenses has been claimed is excluded under clause 4.3 of the policy.
The complainant on the other hand points out in the evidence on affidavit that the bare reading of the clause 4.3, it is apparent that in case of ‘Congenital internal disease’ the waiting period is two years whereas the policy was in force since 31.07.2005. The claim was placed on 04.01.2019.
The actual diagnosis of the disease was ‘Congenital Kyphotic deformity with spastic paraparesis due to D5 D6 D7 hemivertebra’. Clinical profile on admission was ’13 yrs boy presented with progressive bending deformity of back since he was four years old. For last one year he also had difficulty in walking………..’
For further medical details and confirmation, suggestions were sought from the concerned neurosurgeon Dr. Sandip Chatterjee FRCS who attended the patient.
In reply to the questions, Dr. Chatterjee clarified that the condition referred to cannot be diagnosed by looking at external appearances at birth or during childhood, and hence cannot qualify to be an ‘external congenital disease’.
Dr. Chatterje further clarified that the paraparesis developed in last six months prior to surgery.
It is confirmed in Dr. Chatterjee’s mail that the deformity was detected after the boy’s growth spurt in teenage life.
In view of the above, it can in no way be concluded that the disease was a pre-existing one.
While rebutting the claim, the OP could not place before this Commission any exhaustive medical clarification.
There are some aspects in the written version, evidence on affidavit and brief notes of argument filed by the OP which are at once funny, surprising and disappointing.
To illustrate, the OP ‘emphatically’ denies that
- The insured was suffering from some disease.
- The insured had to undergo a surgery
- There was admission and discharge of the patient
- The information of medical treatment was properly conveyed to the TPA
In fact the OP claims that the petitioner had a mala fide intention to realize undue mediclaim benefit from the OP insurance Company and thus the complainant sketched a ‘cock and bull story’.
Now if the Commission has to consider the claim presented by the OP, the first question arises that if it is a cock and bull story sketched out with a mala fide intention to realize undue mediclaim benefit, then why the OP took the trouble of giving an explanation repudiating the claim by stating that ‘the claim is not admissible as it is congenital external disease’ and that is also after almost seven months after placing the claim and after receiving the lawyer’s notice. In that case, the OP should have rejected the claim instantaneously as soon as it was received, considering and establishing the claim as a ‘cock and bull story’ in their response. The OP was at liberty to inform the policyholder that his claim being a ‘cock and bull story’ could not be entertained. The OP was supposed to file an FIR against the policyholder in the concerned police station for placing a false claim.
Common men in our country approach to these insurance companies to get relief from shouldering the burden of huge medical expenses. So far as the documentary evidences filed by the complainant are concerned the genuineness of the complaint does not appear to be questionable. But the manner in which the complainant’s case has been treated by the OP is highly deplorable and deserves strong condemnation. In a desperate attempt to get out of the imbroglio and shrug off the financial liability, they have not even hesitated to say that the poor little boy’s miserable condition was a ‘cock and bull story’. The representations made by the OP at different points of time appear thoroughly unscrupulous.
On meticulous scrutiny of all the aspects of the case, this Commission is of the view that there was gross deficiency of service and absolutely unfair attitude on the OP’s part.
Hence it is
ORDERED
that the complainant case no.185 of 2019 be and the same succeeds on contest but in part.
The only opposite party i.e. the Divisional Manager, National Insurance Company Ltd. is directed to reimburse the treatment expenses as claimed, to the extent of Rs.2,00,000/- with interest @9% for the period from 04.02.2019 to the date of this order. Besides, a further amount of Rs. 50,000/- will have to be paid by the OP to the complainant for his mental agony and harassment and Rs.5,000/- towards litigation cost, within 45 days from the date of this order. In the event of failure to comply with this order, the opposite party will pay cost of Rs.30,000/- by depositing the same in the Consumer Legal Aid account.
Let a plain copy of this order be supplied free of cost to the parties/their Ld. Advocates/Agents on record by hand under proper acknowledgement/sent by ordinary post for information and necessary action.
The final order will be available in the website www.confonet.nic.in.
