Sri Jagadish Chandra Barman, Member,
The facts leading to the filing of the instant case by the complainant may be epitomized as follows:-
Being aggrieved upon the O. P., The Divisional Manager, United India Insurance Company Limited, DO8, Kolkata, 2,Dakshinapan Complex, Gariahat Road, P. O.- Baruipur, the Complainant Sri Gautam Kr. Das filed this instant case being no- C. C. No- 144/ 2019 on 22.8.2019 before this Ld. Commission of Baruipur for proper adjudication.
In this petition, the Complainant clearly stated that he is the Medi-claim Policy holder being no.- 0308002817P105904018 of the United India Insurance Company Limited of the Office mentioned in the above address. As per statement, the Complainant took admission on 13.02.2018 in the Madras Medical Mission Hospital, Mogappair East, Chennai-600037 for the treatment of his ailments. Then Dr. S. Rajan, the Director of Cardiac Surgery, did Aortic Valve Replacement [AVR] using 21MM ON X VALVE on 19/2/2018. Thereafter, the complainant underwent PPI USING BIOTRONIK ENITRA 8 DR-T, BIOTRONIK SOLIA S 56 AND BIOTRONIK SOLIA S 60 on 28/2/2018 in the Madras Medical Mission Hospital. After recovery, the patient [Complainant] was discharged on 06/3/2018 from the Madras Medical Mission Hospital with the advice to take complete rest for three months.
Thereafter, the complainant submitted all the medical treatment’s documents before the O. P. and claimed his benefit Rs. 3,00,000/- only as per terms and conditions of the Medi-claim Policy. The complainant mentioned that he had incurred Rs. 8,06,010/- only for the treatment and surgery of Coronary Angiography[CAG], Aortic Valve Replacement[AVR] and placement of permanent Pacemaker in his body in the Madras Medical Mission Hospital. So the [complainant] claimed Rs. 3, 00,000/- only to reimburse the incurred money. But the O. P. informed that he [complainant] was not entitled to get amount of Rs. 3,00,000/- only but Rs 91,502/- only.
The Complainant also stated in his complaint petition that he was then under cover of Medical Insurance to the tune of at least Rs. 3, 00,000=00 only leaving aside the interest accrued in the policy. As per statement, the Complainant had paid ample premiums to get Rs. 3,00,000/- only as reimbursement amount from the O. P. Hence, the complainant received the said amount of Rs. 91,502/- only by giving an objection. The Complainant wanted to get the calculation sheet for the paid amount Rs. 91,502.00 only to the complainant.
The complainant also wrote a letter through a Ld. Advocate on 12.7.2019 to the Divisional Manger of the United India Insurance Company Ltd. Claiming Rs. 3,00,000/- only to reimburse incurred amount to his client [complainant]within 10 days from the date of receiving his demand notice. The said notice was sent to the O. P. by speed post and was served satisfactorily. But the O. P. did not respond and pay any heed to supply the calculation sheet to the complainant.
Finding no alternative, the Complainant filed this instant case being no- C. C. No- 144/2019 before the D.C.D.R.C., Baruipur for getting the following relieves:-
- To issue an order to the Opposite Party to pay a further sum of Rs. 2,08,498/- only excluding Rs. 91,502.00 only as amount of reimbursement as per terms and conditions of the med-claim Policy ;
2. To issue an order to the Opposite Party to pay a sum of Rs. 50,000.00 only as compensation amount for deficiency in service and unfair trade practice;
3. To issue an order to the Opposite Party to pay a sum of Rs. 25,000.00 only as cost of litigation; and
4. To issue any other order to the Opposite Party as the Ld. Commission may deem fit and proper.
The show cause notice was sent to the Opposite Party and that was served satisfactorily on 16/9/2019. Then the O. P. filed his written version on 8/11/2019. In the W. V., O. P. has stated that this instant case is not maintainable as it is out of jurisdiction and has denied each and every allegation mentioned in the complaint petition. Hence, this complaint case is liable to be dismissed.
The O.P has also stated that the claim of the complainant was settled before and an amount of Rs. 91,502.00 only was paid after necessary deduction on 27/4/2018 vide UTI No-18853874976. The O. P. has opined that the claim has been lodged under policy period from 21.07.2017 to 20.7.2018 Vide Policy no- 0308002817 P105904018. It is also opined in the W. V. that as per prescription of Dr. P. R. Das dated 12.4.2018; the insured/claimant had been suffering from Hypertension since last 8 years. Hypertension is risk factor disease. According to the O. P., any pre-existing conditions 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, the Company shall not be liable to make any payment under the policy in respect of expenses whatsoever incurred by any insured person in connection with or in respect of that disease like hypertension.
The O. P. has also stated under para iv of the W. V. “ As per policy terms and conditions of the clause no-4.1, the opposite party after scrutinised the claim papers have paid after 4 years back in total Rs. 1,25,000.00 only against the claim and as such the enhanced sum insured of Rs. 1,75,000.00 will not be applicable for the said disease.” The said facts were duly communicated to the claimant and the claimant was fully aware of the said facts. Even knowing that the complainant filed this instant case in the Ld. Commission with some malafied intention to make wrongful gain, which is abuse of the process of law.
According to the O. P., the liability of the company shall be only to the extent of the sum insured under the policy enforced at the relevant time, when it was contracted or suffered during the currency of such renewed policy and any subsequent renewal thereof, the relevant provisions regarding enhancement were clearly mentioned in the clause of the said policy are reproduced as hereunder:-
[5.12]……… Any such request for enhancement must be accompanied by a declaration that the insured or any other insured person in respect of whom such enhancement is sought is not aware of symptoms or other indications that may give rise to a claim under the policy. The company requires such insured persons to undergo a medical examination to enable the company to take a decision on accepting the request for enhancement in the sum insured.
[5.13] The company may at any time cancel the policy on grounds of misrepresentation, fraud, non-disclosure of material fact or non-co-operation by the insured by sending fifteen days notice in writing by registered A/D to the insured at his last known address in which case the company shall return to the insured a proportion of the last premium corresponding to the unexpired period of insurance if no claim has been paid under the policy. The insured may at any time cancel this policy and in such event the company shall allow refund of premium at Company’s short period rate table given below provided no claim has occurred up to the date of cancellation. But the table is not mentioned herewith as ready reference.
The O.P. has also argued that O. P. was under contractual obligation to reimburse the claim under terms and conditions of the said policy and accordingly the O.P. has discharged its obligation by reimbursing the claim of the claimant. Hence, the alleged claim for Rs. 3,00,000=00 only is not sustainable in the light of the terms and conditions of the said policy and denied entitlement of Rs. 2,08,498/- only. The O. P. has also denied to pay compensation amount of Rs. 50,000/- only and litigation cost of Rs. 25,000=00 only as there is no deficiency of service and unfair trade practice occurred on behalf of the O. P.
Upon the above averments of the complaint petition, evidences, BNAs and W. V. etc. of both sides, the following points are formulated:-
POINTS FOR DETERMINATION
1]. Is the complainant a ‘Consumer’?
2] Is the O. P. guilty of deficiency in services, and unfair trade practice as alleged by the complainant?
3] Is the complainant entitled to get relief /relieves as prayed for?
EVIDENCES, & BNAS OF THE COMPLAINANT AND O.P
The Complainant filed his evidence on affidavit on 23.12.2019, BNA on 02.02.2021, and the O.P. prayed to treat his W. V. as Evidence on 27.01.2020 which was allowed and filed BNA on 20.12.2021.
DECISIONS WITH REASONS OF THE POINTS 1, 2 and 3.
In relation to point no. 1, “Is the complainant a ‘Consumer’?”- It is very much relevant to say that the Complainant is the Medi-claim Policy holder being no.- 0308002817P105904018 of the United India Insurance Company Limited , DO8, Kolkata, 2,Dakshinapan Complex, Gariahat Road, Police Station- Lake, Kolkata-700068. In the med-claim policy, sum insured Rs. 3,00,000/- only, premium Rs. 9,000.00 only and date of first policy 21.07.1999.As per records available, it had been continuing up to date filing this instant case. The O. P. has also issued money receipts in favour of the Claimant/petitioner
Hence, there is no dispute that Sri Gautam Kr. Das [complainant] is a ‘Consumer ` under definition of Section 2 (d) of the Consumer Protection Act 1986.
In relation to point no-2, “ Is the O. P. guilty of deficiency in service, and unfair trade practice as alleged by the complainant?” and in relation point no-3, “Is the complainant entitled to get relief /relieves as prayed for?”-It is very much worthy to mention that the O. P., after scrutinization of the documents of the claim and necessary deduction, paid in total Rs. 91,502.00 .00 only to the patitioner on 27.04.2018 against the claim vide UTI No-18853874976.
It is pertinent to mention that Mr. Chandrani Mahalanobis, Senior Divisional Manager , United Insurance Co. Ltd. Division –VIII, Kolkata wrote a letter to the complainant on 5th Sept.2018 in which he clearly mentioned that the clamant Sri Gautam Kr. Das sent an e-mail claiming his reimbursement Rs. 3,00,000/- and the matter was taken up with the competent authority. As per statement “the advice for surgery was given by the Dr. in the year 2017, hence we would consider the sum insured for the year 2016-17 which was Rs. 2,50,000=00 only and would pay 75% of Rs. 2,50,000.00/- i.e., Rs. 1,87,500.00 as total claim amount. Since an amount of Rs. 91,502.00 had already been paid, the difference amount of Rs. 95,998/- will be transferred to your account, in case you agree for the same.”But that amount was also not transferred to the account of the claimant/petitioner.
The petitioner has claimed Rs. 3, 00,000=00 only as reimbursement amount for the treatment and surgery of Coronary Angiography[CAG], Aortic Valve Replacement[AVR] and placement of permanent Pacemaker out of incurred amount Rs. 8,06,010/- only. As per documentary evidences available, it is clear to us that in the Medi-claim policy, sum was insured Rs. 3,00,000/- only, premium was Rs. 9,000.00 only and date of first policy 21.07.1999. As per records available, the policy had been continuing up to date filing this instant case. The O. P. has also issued money receipts in favour of the Claimant/petitioner. Ergo, the claim of the insured and petitioner is reasonable and justified to get Rs. 3,00,000=00 [ Rs. Three lacs] only from the O. P. as reimbursement amount. Hence, it is clear to us that there is clear deficiency of service and unfair trade practice occurred on behalf of the O. P.
Therefore, the Opposite Party is liable to pay further Rs. 2,08,498.00 only to the complainant as reimbursement amount within 45 days from the date of issuing this Order with simple interest 9% p. a. from the date of filing this instant case i.e., 22.8.2019 till realization.
The O. P. is also directed to pay Rs. 50,000.00 only as compensation amount and Rs. 25,000.00 only as cost of litigation within 45 days from the date of issuing this order.
As a result, the complaint case is succeeded.
Hence, it is
ORDERED
that the complaint case be and the same is hereby allowed on contest against the sole O. P. with a Litigation Cost of Rs.25, 000=00 ( Rs. Twenty five thousand) only to be paid to the Complainant within 45 days from the date of issuing this Order.
The Opposite Party is liable to pay further Rs. 2,08,498.00 [ Rs. Two lacs eight thousand four hundred and ninety eight ] only to the Complainant as reimbursement amount within 45 days from the date of issuing this Order with simple interest 9% p. a. from the date of filing this instant case i.e., 22.8.2019 till realization.
The O. P. is also directed to pay Rs. 50,000.00 [ Rs. Fifty thousand] only as compensation amount for deficiency in service and unfair trade practice occurred within 45 days from the date of issuing this order.
The Complainant is at liberty to file an Execution Case against the O. P., before this Ld. Commission for non-compliance of the order by the O. P., after expiry of 45 days.
Let copies of the order be supplied to all the parties concerned in either speed post /registered post free of cost as per rule.
The final order be also available in www.confonet.nic.in .
Prepared and Corrected by me.
( Shri Jagadish Chandra Barman)
(MEMBER)
