This is a complaint made by one Suresh Chandra Shaw against the Divisional Manager, Star Health & Allied Insurance Co. Ltd. and Desun Hospital & Heart Institute, praying for a direction upon the OPs to pay and settle the claim amount of Rs. 29,815/- along with interest @ 18% p. a. plus compensation and litigation cost for a sum of Rs. 50,000/- and Rs. 10,000/-, respectively.
Facts, in brief, are that the Complainant took a mediclaim policy, namely, “Senior Citizens Red Carpet Insurance Policy” for a sum assured of Rs. 1,00,000/- from the OP No. 1 and is continuing the same for the past few years. Complainant fell seriously ill, as he sufferred severe left side headache and vomiting and thereafter, he was examined by Dr. Amarnath Basak. As per the advice of the said doctor, he got admitted at the OP No. 2 hospital on 09-12-2014 under the care of Dr. Amar Nath Basak and Dr. Kaushik Sen, where he was diagnosed for “acute migraine with infarcts in both MCA territories, type 2 diabetes mellitus and hypertension. After thorough treatment, he was discharged from there on 11-12-2014. It is stated that the Complainant duly informed the OP No. 1 about his admission and through the OP No. 2 hospital, a provisional bill of Rs. 19,325/- was sent to the OP No. 1 on 10-12-2014. It is alleged that the OP No. 1, without considering the matter properly and also without verification of all medical documents, treatment sheets, prescription of doctor, unilaterally recommended for payment of Rs. 1,400/-. Being dissatisfied with the above recommendation, he sent a letter to the OP No. 1, but the latter has not bothered to give any reply to such letter. Thereafter, he met the officials of OP No. 1 several times, but to no avail. Hence, this case.
OP No. 1 filed written version and denied all the material allegations of the complaint. It is submitted by this OP that the claim is liable to be dismissed. It is further contended that the insurance policy is subject to conditions, clause, warranties, exclusions, etc. It is also stated that rights and liabilities of the parties are strictly circumscribed by the contract of insurance and only such contractual rights can be enforced and the same has been endorsed by the Hon’ble National Commission. It is stated that at the time of inception of the policy, the Insured did not disclose the medical history/condition of health properly for which cashless authorization was denied and the claim was finally repudiated on 10-06-2015 on the ground of non-disclosure/misrepresentation of material facts. As per condition no. 7 of the policy, if there is any misrepresentation/non-disclosure of material fact by the Insuree, the Insurance Company is not liable to make any payment in respect of any claim. It is further asserted that as per the contract of insurance, it is the duty of the proposer to disclose all material facts to the Insurer in order to evaluate the risk by the Insurer properly and to decide whether the risk would be accepted or rejected based on the principle of utmost good faith. So, the OP No. 1 has prayed for dismissal of the case.
Decision with reasons
Complainant filled Affidavit-in-Chief, wherein he has reiterated the facts mentioned in the written complaint. Thereafter, OP No. 1 filed questionnaire, to which Complainant replied under affidavit. OP No. 1 also filed Affidavit-in-Chief to which Complainant filed questionnaire and the OP No. 1 thereafter filed reply. Subsequently, argument was advanced from the sides of both the contesting parties.
The main point for determination is whether the Complainant is entitled to the reliefs as prayed for.
First relief of the Complainant is for a direction upon the OP to pay Rs. 29,815/- with 18% interest p.a. It is alleged by the OP No. 1 that the instant claim of the Complainant is not payable for non-disclosure/misrepresentation of material fact. It is alleged that at the time of opting for the insurance, the Complainant did not disclose his pre-existing disease.
It appears from the documents on record that the Complainant underwent treatment (VP shut surgery along with DM and HTN) at the Institute of Neurosciences Kolkata during the period from 30-10-2010 to 08-11-2010.
Against this backdrop, the question survives, whether the claim has been rightly repudiated or not.
As per convention, a proposer is subjected to various routine tests and the general condition of the proposer is duly examined by the panel doctor of the Insurance Company. Insofar as the Complainant was a Senior Citizen, we feel, the panel doctor, who examined the Complainant, should have been extremely vigilant in discharging his duty. We fail to understand, while the Complainant was suffering from DM and HTN etc. since the year 2010, how come the said facts escaped the attention of the panel doctor of the OP Insurer. It is for the Insurer to tighten its belt to inculcate a sense of accountability amongst its panel doctors rather than blaming others for the lackadaisical approach of its panel doctors.
Be that as it may, on a bird’s eye view of the terms and conditions of “Senior Citizens Red Carpet Health Insurance Policy”, we find that, in terms of Exclusion Clause 1, the Company shall not be liable to make any payment under the policy in case of pre-existing diseases until 12 consecutive months of continuous coverage have elapsed, since inception of the first policy.
In the instant case, admittedly, the policy commenced w.e.f. 02-07-2013 and the disputed claim pertains to the treatment underwent by the Complainant in between the period from 09-12-2014 to 11-12-2014. It is absolutely clear, therefore, that the exclusion clause is not applicable in respect of the present claim of the Complainant. So, by repudiating the claim of the Complainant, no doubt, the OP No. 1 has meted out gross injustice to the Complainant.
From the photocopy of Impatient Final Bill dated 11-12-2014 and money receipt thereof, it appears that the Complainant paid a sum of Rs. 29,815.00 to the OP No. 2. However, although the Complainant has claimed the said amount, it appears from the terms and conditions of the policy that this policy is subject to co-payment of 50% of each and every claim arising out of pre-existing diseases. Going by this clause, the Complainant is entitled to Rs. 14,908.00.
As regards the claim of the Complainant for compensation, we are not inclined to award any amount on this score for want of any explanation from the side of the Complainant to justify this award. However, Complainant must be entitled to the litigation cost of Rs. 5,000/-.
Hence,
O R D E R E D
That RBT/CC/90/2015 be and the same is allowed on contest against the OP No. 1 in part and dismissed ex parte against the OP No. 2. OP No. 1 is directed to pay Rs. 14,908.00 within two months from the date of this order along with litigation cost Rs. 5,000.00.
