In the Court of the
Consumer Disputes Redressal Forum, Unit -I, Kolkata,
8B, Nelie Sengupta Sarani, Kolkata-700087.
CDF/Unit-I/Case No. 213 / 2010.
1) Sri Swahapati Ganguly,
CI-687/1, Sukantanagar, Sector-IV,
Salt Lake, Kolkata-700098. ---------- Complainant
---Versus---
1) The Divisional Manager, United India Insurance Co. Ltd.,
Division-IV, Code-0304400,
2, Brabourne Road, Kolkata-700001.
2) Medicare TPA Service (I) Pvt. Ltd.,
6, Bishop Lefroy Road, Kolkata-700020. ---------- Opposite Parties
Present : Sri Sankar Nath Das, President.
Dr. Subir Kumar Chaudhuri ,MEMBER
Smt. Sharmi Basu ,MEMBER
Order No. 1 9 Dated 19/04/2012.
The petition of complaint u/s 12 of the C.P. Act, 1986 has been filed by the complainant Swahapati Ganguli against the o.ps. United India Insurance Co. Ltd. and another. The case of the complainant in short is that complainant purchased at a valuable consideration of a medical insurance policy from o.p. no.1 in the year 2008 and it was for the period from 28.6.08 to 27.6.09 and complainant paid total sum of Rs.14,520/- as premium for such insurance policy covering himself and his wife for a sum of Rs.2,25,000/- each and the said policy offered cashless hospitalization and o.p. no.2 issued a card for cashless hospitalization and during the subsistence of the said insurance policy complainant, on 18.12.08 very much within the insurance coverage period, was admitted at AMRI Hospital, Salt Lake suffering from chest discomfort, acute mio-infarction, thrombosis, etc. and he was discharged from there on 23.12.08 and he had to incur a sum of Rs.1,50,000/- for treatment at AMRI Hospital and he applied for cashless benefit but o.ps. refused to pay the same vide letters dt.20.12.08 and 22.12.08 on the plea of pre-existing diseases and the attending doctor Shuvanan Roy stated repeatedly following letters 22.12.08 and 20.12.08 that the patient was non-diabetic and non-hypertensive and the initial request form sent to mediclaim was on a error on his part, but o.p. no.2 did not pay heed to the doctor’s statement and finally o.p. no.1 on 26.3.09 repudiated the instant claim on the ground of pre-existing disease and o.p. no.2 vide letter dt.17.4.09 repudiated the claim on the ground referred to by o.p. no.1 and the repudiation letters of o.p. nos. 1 and 2 were dt.26.3.09 and 17.3.09. Hence, the case.
Both o.ps. had entered their appearances in this case by filing w/v and denied all the material allegations labeled against them and prayed for dismissal of the case.
Decision with reasons:
We have gone through the pleadings of the parties, evidence and documents in particular. It is an admitted position that the complainant was not defaulter in any manner whatsoever at the relevant point of time and he was offered with cashless benefit for his treatment. Herein the instant case o.ps. repudiated the claim of the complainant on the plea of pre-existing disease. It is settled principle of law that on the receipt of payment of premium policy is liability of the insurance company starts and o.p. cannot shirk off in the manner which has been done in the instant case. That apart, in this context we would like to refer to Hon’ble National Commission’s decision published in III (2009) CPJ 6 (NC) wherein Hon’ble National Commission held that in case of pre-existing disease suppressed by insured the onus to prove of pre-existing disease at the time of taking of policy lies of insurer. Herein the instant case there is nothing on record to that effect on behalf of o.ps. prior to taking 1st insurance premium.
Therefore, we hold that o.ps. had sufficient deficiencies being service providers within the ambit and scope of C.P. Act to its consumer / complainant and we hold that the complainant is entitled to relief.
Hence, ordered,
That the petition of complaint is allowed on contest with cost against the o.ps. O.ps. are jointly and severally directed to pay to the complainant a sum of Rs.1,50,000/- (Rupees one lakh fifty thousand) only towards reimbursement medical expenses incurred by complainant for his treatment together with interest @ 9% p.a. from the date of repudiation of the claim till the date of realization and are further directed to pay a compensation of Rs.30,000/- (Rupees thirty thousand) only for his 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 @ 9% 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.
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MEMBER MEMBER PRESIDENT
