In the Court of the
Consumer Disputes Redressal Forum, Unit -I, Kolkata,
8B, Nelie Sengupta Sarani, 4th Floor, Kolkata-700087.
CDF/Unit-I/Case No. 46 / 2010 .
1) Mrs. Soma Mukherjee,
36/B, Kabir Road, Kolkata-700026. ---------- Complainant
---Versus---
1) The Divisional Manager, United India Insurance Co. Ltd. (D.O.-x),
Apeejay House, 7th Floor, 15, Park Street, Kolkata-700016.
2) The Manager-Operations,
Heritage Health Service Pvt., C/o. Heritage Health TPA Pvt. Ltd.,
Nicco House, 5th Floor, 2, Hare Street, Kolkata-700001. -------- Opposite Parties
Present : Sri Sankar Nath Das, President.
Dr. Subir Kumar Chaudhuri, Member.
Smt. Sharmi Basu, Member
Order No. 23 Dated 30/07/2012.
The instant case has been filed by the complainant against the o.ps. with allegation of deficiency in service, which is very much within the scope and ambit of the COPRA.
In a nutshell, the case of the complainant is that the complainant is holding Health Insurance Policy of Rs.1 lac for self and for her son of Rs.50,000/- from o.p. no.1 viz. United Insurance Co. Ltd. since 14.2.06 through o.p. no.2 viz. Heritage Health Service Pvt. Ltd. (TPA).
She is paying the policy premium regularly and the last policy premium paid on 10.2.09 and accordingly the o.p.1 issued Health Insurance Policy and the said policy is covered and valid from 14.2.09 to 13.2.10 (midnight).
Abhishek Mukherjee, son of the complainant, felt some problem in his nose and took medical advise in the month of Feb, 2009 and it was detected that said Abhishek Mukherjee was suffering from ‘Deviation of Nasal Septam” (DNS) and he was advised for early surgery by his Physician and he was admitted to N.G. Nursing Home on 1.3.09 under supervision of Dr. Kaushik Das and on 3.3.09 the operation was done by the surgeon and said Abhishek Mukherjee was discharged from the nursing home on 7.3.09.
The complainant incurred a total expenses of Rs.47,487/- towards treatment of her son who is under the beneficiary of that policy and she, thereafter, submitted her claim to the o.p. no.1 for re-imbursement of the medical benefit in the month of March, 2009.
But on 10.1.09 the o.p. no.2 sent a letter to the complainant repudiating the claim of the complainant enclosing therein a reference letter of o.p. no.1. The o.p. no.1 repudiated the claim on the ground that the claim was not admissible as per exclusion clause no.4.1 of the Policy which runs as follows:
“Any pre-existing condition(s) as defined in the policy, until 48 months of continuous coverage of such insured person have elapsed, since inception of his/her first policy with the company.
Pre existing condition / disease definition any condition, ailment of injury or related condition(s) for which insured person had signs or symptoms, and/or received medical advice / treatment, within 48 months prior to his/her first policy with the company”.
As per the complainant that the repudiation of the claim in question is unjustified and for this complainant has to suffer mental agony and financial loss. Hence, she filed the instant case before this Forum for redressal of his dispute and prayed for relief as mentioned in the complaint.
O.ps. have entered their appearance in the instant case by filing w/v and they have denied all the material allegations lebelled against them and prayed for dismissal of the instant case in limini.
Decision with reasons:
01. After scrutinizing all the documents brought before this Forum and hearing every nook and corner from both the parties it appears to this Forum that the complainant being Health Insurance Policy Holder, was regular in payment of premium and her son is beneficiary of that policy.Moreover, complainant is under this policy from 14.2.06 and from then her son was covered by the policy as beneficiary.
02. Ld. Counsel for the o.ps. has raised the point that as the expenses incurred by the complainant for the operation done for Deviated of Nasal Septum, (DNS) of her son. The o.ps. submitted that cartilaginous septum is located in between the two nostrils. It is structurally straight and is centrally located and can be deviated either due to trauma or since birth (congenital) leading to reduced passage among one of the nostrils. It is beyond doubt that as per exclusion clause of the policy (vide no.4.1) congenital disease (external and internal) has no coverage under the policy.
03. Now, the crux of the instant case is that whether the DNS of the son of he complainant was congenital or not. From the record it reveals that o.ps. did not give any expert opinion to establish that the DNS of he son of the complainant was congenital. On the other hand, from the record it reveals that Dr. Kaushik Das, under whose supervision the patient was admitted at nursing home, never mentioned that DNS of the patient was congenital. Therefore, it could not be established by the o.ps. in any manner whatsoever that the DNS of the patient in question was congenital. Another point is needed to be mentioned that before giving any policy, it is normal and essential responsibility of the insurer to perform health check of the insured and beneficiary of any policy by one or more panel medical practitioner(s) of the insurer. In the instant case the mediclaim policy in question was taken by the complainant initially on 14.2.06. From then till the date of operation that is till 3.3.09 no of panel doctors have detected that the son of complainant has congenital DNSand no document can be produced by the o.p.s that it was within the knowledge of the complainant. Only after the raising of claim of reimbursement bill by the complainant, o.ps. raised the point of congenital disease and moreover could not establish that point through medical expert opinion.
As per above discussion we are of the opinion that the o.ps. have miserably failed to establish that reason of repudiation of the reimbursement claim of the complainant by the o.ps. was justified. We are of the opinion that the repudiation of claim in question b y the o.ps. is not at all justified and thus the o.ps. have committed deficiency in rendering their service to the consumer / complainant and claim of reimbursement towards medical expense of her son amounting …. is justified.
To decide whether the complainant is eligible to be compensated by the o.ps., following discussion is advanced. It is very natural that when any person takes medical policy, he / she has belief that at the time of reimbursement of medical expenses, they shall not be harassed unnecessarily and for that belief on good faith the insured gives premium amount regularly to the insurer. It is not at all desirable that being service provider insurer would harass or repudiate the justified claim of insured adopting any tricky way. In the instant case due to unjustified repudiation of claim of the complainant by the o.p1. Complainant has to suffer unnecessary harassment and mental agony due to her no fault. Therefore, it is our strong believe that the complainant is entitled to get compensation from the o.p1. Moreover, we are of the opinion that as o.p. no.2 is TPA (Third Party administrator) of o.p. no.1, then liability of compensation towards complainant is upon o.p. no.1.
Ld. counsel of o.p1. has referred a remarkable judgment vide no. SCC 1999(6) 451. We have gone through the judgment. With deepest regards to that judgment, we are of the opinion that as in the instant case the o.p1. could not establish that the cause of repudiation was justified, therefore, the aforesaid judgment is not applicable in favour of the o.ps.
Hence, ordered,
The case of the complainant is allowed on contest with cost against the o.p. no.1 and dismissed without cost against o.p. no.2. O.p. no.1 is directed to pay the complainant Rs.47,487/- (Rupees forty seven thousand four hundred eighty seven) only towards the reimbursement of expenses of treatment of the son of the complainant. O.p. no.1 is also directed to pay Rs.10,000/- (Rupees ten thousand) only to the complainant as compensation for her mental agony and financial loss due to deficiency in service of the o.p. no.1.
All the aforesaid direction should be complied by o.p. no.1 within 45 days from the date of communication of this order, i.d. an interest @ 9% 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.
