DATE OF FILING : 30-09-2011.
DATE OF S/R : 16-03-2012.
DATE OF FINAL ORDER : 21-09-2012.
Smt. Ava Mondal,
wife of Sri Amiya Mondal,
46/5, Hazra Para Lane, Belur, P.O. & P.S. Bally,
District –Howrah--------------------------------------------------------------- COMPLAINANT.
- Versus -
1. The Divisional Manager,
The Oriental Insurance Company Limited,
P-4, Dobson Lane 4th Floor,
Howrah – 711101.
2. The Divisional Manager,
Heritage Health Service Pvt. Ltd.
NICCO House 5th Floor,
2, Hare Street,
Kolkata – 700001.
3. The Divisional Manager,
The Oriental Insurance Company Ltd.
J.P. Hub ( 4th floor ),
4, Lyons Range,
Calcutta – 700001. . -----------------------------------------------OPPOSITE PARTIES.
P R E S E N T
President : Shri T.K. Bhattacharya, M.A. LL.B. WBHJS.
Member : Shri P.K. Chatterjee.
Member : Smt. Jhumki Saha.
F I N A L O R D E R
It is the specific grievance of the complainant Smt. Ava Mondal that even
after receiving the premium regularly for medi claim policy being no. 311700/48/2009/2257, since 2005 issued by O.p. nos. 1 & 3 through o.p. no. 2 in her favour, O.Ps. have arbitrarily repudiated the claim of the complainant so lodged with the o.ps. on 19-11-2008. And alleging deficiency in service on the part of the o.ps. complainant filed this petition U/S 12 of the C.P. Act, 1986 ( as amended upto date ) praying for a direction to be given upon the o.ps. to pay the claim amount of Rs. 12,680/- together with a compensation of Rs. 20,000/- for causing mental agony and harassment along with other relief.
Brief fact of the case is that on being advised by some doctor, namely, Dr. S.K. Mukherjee, petitioner got admitted to C.M.C. Vellore for her treatment on 24-10-2008 vide annex prescription of Dr. Mukherjee dated 30-09-2008 as she was suffering from diabetes Mellitus Type II. And after one day of hospitalization and treatment she was discharged on 25-10-2008 vide annexure “Discharge Summery “ provided by C.M.C., Vellore, Cardiology Unit II after incurring an expenditure of Rs. 12,680/-. Thereafter, on 19-11-2008 complainant filed a claim of Rs. 12,680/- along with all relevant documents and on 02-03-2009 one reminder letter was sent requesting for the release of such claim amount in favour of the complainant. But o.p. no. 2 sent one letter dated 19-02-2009 whereby the claim of the complainant was repudiated by o.p. no. 2 on the ground of pre-existing disease which is not covered as per Policy Clause No. 4.1 vide annexure letter dated 19-02-2009 of o.p. no. 2. And the copy of that letter dated 19-02-2009 was also sent to o.p. no. 1, Insurance company. After such repudiation, complainant’s husband again wrote to o.p. no. 1 on 28-04-2009 requesting for the release of same claim amount vide annexure letter dated 28-04-2009 clarifying the same as was done in letter dated 02-03-2009 that in Discharge Summery dated 25-10-2008, CMC Vellore had mistakenly written that the “complainant is a known patient of diabetic since 20 years and having hypertension since past 9 years. Again complainant’s husband wrote another letter on 27-11-2009 to o.p. no. 1 with the same request. Finally, on 10-02-2010, o.p. no. 1 sent one letter to o.p. no. 2 requesting to look into the matter by way of reconsidering the claim of the complainant. But no fruitful result came out. And lastly on 03-11-2010, complainant sent one lawyer’s letter to o.p. no. 1. But all efforts went in vain. And finding no other alternative, complainant filed this instant petition. Notices were served upon o.ps. O.ps. appeared and filed written version.
DECISION WITH REASONS :
We have carefully gone through the written version and interrogations filed by the o.ps. and noted their contention along with the replies as filed by the complainant. O.ps. have denied all allegations put forward by the complainant on affidavit. Even o.ps. vide para no. 13 of their written version has submitted that complainant had falsely made a prescription through Dr. S.K. Mukherjee and as per direction of the complainant. C.M.C., Vellore provided a Discharge Summery from which the past history of the complainant about her diabetes problem for 20 years and hypertension for 9 years was disclosed. Here, we fail to understand that in one hand o.ps. have agreed to admit the remark made by C.M.C., Vellore in their Discharge summary dated 25-10-2008, on the other hand they are making a statement that complainant had falsely made a prescription through, Dr. S.K. Mukherjee and only at the insistence of the complainant, C.M.C., Vellore, provided the ‘Discharge Summary’ dated 25-10-2008. We think that o.ps. have forgotten the fact that complainant is a senior citizen and her husband is again older than her. For such a small amount of Rs. 12,680/- our common sense does not allow us to believe that such a couple would ever go for doing such thing with a malafide intension. Moreover, when complainant submitted proposal form, she disclosed all material informations about her health. Even she disclosed that she had cataract operation of her both eyes vide clause no. 13( i ) of the proposal form. If she has had an ill motive, she could have suppressed it. And in annexure A which is attached with the proposal form, i.e., in ‘Diabetes Questionnaire’, as against question no. 4, she disclosed her Blood Sugar Fasting as 138 mg. and Blood Sugar PP – 137 mg. on 19-01-2005. Moreover, in Annexure ‘B’ attached with the same proposal form which was filled up by the consulting physician, Dr. A.K. Bhadra, there was no significant past history of disease of the complainant at the time of taking the said mediclaim policy. As a normal human being, all of us are having pressure and sugar. If it is not within the knowledge of the complainant, how complainant could be held responsible for not disclosing the same. And on being satisfied with the informations supplied by the complainant, o.ps. had issued the policy, and it was renewed from time to time on payment of regular premiums. People take mediclaim policy to cover the unforeseen risk of hospitalization that involves a considerable amount. And ours is a welfare state, we are to keep in mind the very spirit of a welfare state. O.ps. are receiving premium regularly and at the time of making payment of the claim amount they are taking all whimsical pleas, which should not be allowed. And when o.p. no. 1 wrote a letter dated 10-02-2010 to o.p. no. 2 requesting them to reconsider the instant matter, o.p. no. 2 remained silent without doing anything, which also constitutes a part of deficiency in service. Actually, mere inclusion of one clause as pre-existing disease , i.e., clause 4.1 in the policy condition does never allow o.p. to act in such a manner which is nothing but arbitrary and illegal in our opinion. And since 2008, by not paying the legitimate claim of the complainant, o.ps. have neglected to discharge their duty towards the complainant. Accordingly, we hold o.ps. to be deficient in service.
Hence,
O R D E R E D
That the C. C. Case No. 78 of 2011 ( HDF 78 of 2011 ) be allowed on contest.
That the O.P. nos. 1, 2 & 3 are jointly and severally directed to pay the claim amount of Rs. 12,680/- along with a compensation of Rs. 10,000/- and litigation cost of Rs. 2,000/- within one month from this order i.d. the entire amount of Rs. 24,680/- shall carry an interest @ 12% p.a. till full realization.
Supply the copies of the order to the parties, as per rule.
