DATE OF FILING : 24/02/2015
DATE OF S/R : 06/04/2015
DATE OF FINAL ORDER : 30/03/2016
SWAGATA GHOSH
S/O. Sri Sasadhar Ghosh,
220/4K, Banaras Road, P.O. Kona,
P.S. Liluah,
District Howrah. 711 114.………………………………………………….. COMPLAINANT.
1. The General Manager,
Bajaj Allianz General Insurance Company,
Head office at GE Plaza,
Airport Road, Yerwada,
Pune 411 006.
2. The General Manager,
Bajaj Allianz General Insurance Company
Regional Office at Mani Square, 6th Floor, No. 164,
Maniktala Main Road, Mani Square premises No. 41,
Canal Circle Road,
Kolkata. 700 054.
3. The General Manager,
West Bank Health and Wellness Institute
120/1, Andul Road,
Howrah. 711 103.
4. Dr. Nilanjan Patranabish,
West Bank Health and Wellness Institute
120/1, Andul Road,
Howrah. 711 103.
5. Sri Subroto De
Authorized Agent Of
Bajaj Allianz general Insurance Company,
Mani Square, 6th Floor, No. 164, Maniktala Main Road,
Mani Square premises No. 41, Canal Circle Road,
Kolkata. 700 054.………………………………………………………………OPPOSITE PARTIES.
P R E S E N T
Hon’ble President : Shri B. D. Nanda, M.A. ( double ), L.L.M., WBHJS.
Hon’ble Member : Smt. Jhumki Saha.
Hon’ble Member : Shri A.K. Pathak.
F I N A L O R D E R
1. Complainant, namely, Swagata Ghosh, by filing a petition U/S 12 of the C. P. Act, 1986 ( as amended up to date ) has prayed for a direction to be given upon the o.ps. to restart the medical claim policy in question, along with compensation and litigation costs and other relief or reliefs as the Forum may deem fit and proper.
2. Brief fact of the case is that complainant was having a medical claim policy issued by O.Ps. 1, 2 is a since 08/04/2010. The policy was renewed regularly on payment of requisite premium amount. Accordingly, it was renewed in 2014 with the period 09/04/2014 to 08/04/2015 with sum insured of Rs.3,00,000/- vide annexure policy document baring No. OG-11-2401-6001-00000004. During this policy period, complainant was admitted to O.P. 3 under O.P. 4 on 12/05/2014. But after having signed on a Discharge on risk Bond, complainant was removed from O.P. 3 to some other hospital. There he did not got the cashless benefit from O.Ps. 1 &2. So, after being discharged from that hospital, complainant filed claim form for getting the reimbursement of all expenses incurred including the cashless benefit being Rs.1,83,000/-. O.Ps. 1 & 2 also released a sum of Rs.1,70,000/-but vide their letter dt.19/12/2014, they have cancelled the policy in question on the ground that complainant had pre-existing disease which he did not disclose at the time of taking policy. And this kind of opinion was built up by a noting that was made by O.P. 4 when complainant was admitted to O.P. 3 on 12/05/2014. But it is alleged by the complainant that it was not correct. Moreover O.P. 4 gave a certificate on 19/12/2014 stating therein that such noting was made at the time of admission in o.p no.3 on 12/05/2014 as per the history of the patient herein the complainant, given by his relative at the time of admission. But as per complainant’s brother, complainant is suffering from the respiratory problem and hypertension for three years vide annexure dt. 19/12/2014, a certificate of O.P. 4. But O.Ps. 1 & 2 sent a letter on 19/12/2014 informing the complainant that as he was suffering from COPD (Chronic Obstructive Putmonary Disease) since 30 years and hypertension on since 2009 and this entire fact was not disclosed by him at the time of taking policy, so, the policy is being cancelled by them although they reimbursed an amount of Rs.1,70,000/- to the complainant on account of hospitalization. So, alleging deficiency in service on the part of the O.Ps., complainant filed this instant case with the aforesaid prayers.
3. Notices were served up on O.Ps. O.Ps. 1, 2, & 4 appeared and filed W/V. other O.Ps. did not file any W/V. Accordingly, the case was heard on contest against O.Ps. 1, 2, & 4 and exparte against O.Ps. 3 & 5
4. Upon pleadings of both parties two points arose for determination :
i) Is there any deficiency in service on the part of the O.Ps. ?
ii) Whether the complainant is entitled to get any relief as prayed for ?
DECISION WITH REASONS
5. We have carefully gone through the W/V and additional W/V filed by O.Ps. 1, 2, & 4 with documents and noted their contents. O.Ps. 1 & 2 have not filed any copy of proposal form submitted by the complainant and the terms and conditions showing exclusion clause while talking this instant policy. Moreover since it is a mediclaim policy, the insurer being O.ps. 1 & 2 should always obtain medical checkup report from the proposer at the first instance. But it has became their common practice that without having pre-medical report, they are issuing the mediclaim policy to the customer herein the complainant. And in this case they have taken a amount of Rs.14,665/- as premium which is quite a big amount. Since 2010 they were receiving such premium amount from the complainant without any medical report which is nothing but an incorrect practice leading towards unfair trade practice on their part. It is also our common knowledge that the agent of the insurer, herein O.P. 5 always fills up the form, the proposer is to put his or her signature. And it is done at the instruction of such agent who acts on behalf of the principal, herein O.Ps. 1 & 2. The institutions like O.Ps. 1 & 2, should train up their agents in a fair manner. But in practice, the agents as well as their principals are always interested to receive the premiums from the customers even adopting some unfair means, which should not be allowed to be perpetuated. O.P. 4 in its W/V has categorically stated that the initial noting is made as per the history of the patient told by his family members. And we also know that in usual hospitalization case, only this thing happens. So, we do not find any deficiency on the part of O.P. 4. But it is true that in the pathological report of the complainant the name of the complainant is appearing as a female as Mrs. Swagata Ghosh which was done by O.P. 3 and it is nothing but a gross mistake on the part of O.P. 3. But O.P. 3 did not filed any written version.
Hence,
O R D E R E D
That the C. C. Case No. 79 of 2015 ( HDF 79 of 2015 ) be allowed on contest with costs against the O.P.nos.1,2,3 and dismissed against o.p nos 4 and 5 without cost.
That the O.P. nos 1 and 2. are jointly and severally directed to restart the mediclaim policy in question on receipt of appropriate premium amount from the complaint within 30 days from this order id Rs.50 per day shall be imposed upon them till actual issue of the same.
That the O.P. no. 3 is directed to pay rupees 8000/- as compensation and Rs.2,000 as litigation costs within 30 days from this order id the entire amount shall carry and interest @ 8% p.a. till actual payment.
The complainant is at liberty to put the decree into execution after expiry of the appeal period.
Supply the copies of the order to the parties, as per rule.
DICTATED & CORRECTED
BY ME.
( Jhumki Saha)
Member, C.D.R.F., Howrah.
