West Bengal

South 24 Parganas

CC/606/2014

Biswapratim Roy, being the minor son Dr. Bikash Roy, S/O Late Bibekananda Roy. - Complainant(s)

Versus

The Manager, Grievance Department, Star Health and allied Insurance Co Ltd. - Opp.Party(s)

05 Sep 2016

ORDER

DISTRICT CONSUMER DISPLUTES REDRESSAL FORUM

SOUTH 24 – PARGANAS , JUDGES’ COURT, ALIPORE KOLKATA-700 027

 

C.C. CASE NO. _606__   OF ___2014____

 

DATE OF FILING : 18.12.2014     DATE OF PASSING JUDGEMENT:      5/9/16

 

Present                        :   President       :   Udayan Mukhopadhyay

 

                                        Member(s)    :  Smt.  Sharmi Basu                                            

 

COMPLAINANT                  :  Biswapratim Roy,, minor son being represented by his father and natural guardian Dr. Bikash Roy,s/o late Bibekananda Roy of “SOVA” no.46, Jubili Park, Brahmapur, Battala, P.S Brahmapur, Kolkata – 96.

 

-VERSUS  -

 

O.P/O.Ps                                :  1. The Manager, Grievance Department Star Health and Allied Insurance Co. Ltd. Valluvarkottam, High Road, Nungambakkam High Road, Nungam Bakkam Chennai-34.

                                                 2.     The Zonal Manager, Claim Department, Star Health and Allied Insurnace Co. Ltd. 75-C, Park Street (5^th Floor), Kolkata – 16.

                                               3.    The Branch Manager, Star Health And Allied Insurance Co. Ltd. 200/2C, Rash Behari Avenue, 3^rd Floor, Gariahat, Kolkata – 29.

                                                

________________________________________________________________________

 

                                                            J  U  D  G  E  M  E  N  T

 

            Smt. Sharmi Basu, Member

            The petition of complaint made under section 12 of the C.P Act ,1986 has been filed by the complainants against the O.Ps on the ground that complainant was a bonafide medicalaim policy holder under portability being Policy No.P/191112/112/01/2014/003205  since 3.10.2013 to midnight of 2.10.2014. During the policy period complainant felt back pain and visited with Dr. Saumyajit Basu on 9.4.2014 who advised the complainant to take admission at Park Clinic for necessary surgery complainant underwent Kyphosis correction Surgery on 29.4.2014 and was discharged from Park Clinic on 6.5.2014 and complainant’s father had to spend Rs.5,18,111/- . Complainant’s father submitted claim of Rs.3 lacs but the O.P-1 repudiated the claim . Complainant also sent a letter to the O.P through his Ld. Advocate to disburse the said amount but the O.Ps refused to disburse the same. Hence, this case praying for disbursement of policy amount of Rs.3 lacs, compensation of Rs.3,50,000/- and litigation cost of Rs.50,000/- and Rs.3 lacs for suffering of the ailing son of the complainant etc.

            O.P-2 filed written version and contested the case denying all the material allegations contending inter alia that complainant underwent medical treatment of the above health condition which existed prior to inception of the subject policy on 3.10.2013 under portability what albeit was within the knowledge of the complainant’s father but he did not disclose the said fact at the time of inception of the said policy in the proposal form and accordingly the claim of the complainant is repudiated. Hence, the O.P prays for dismissal of the case .

Points for Decision

1. Whether the complainant is a Consumer or not.
2. Whether there is any deficiency in service on the part of the O.Ps or not.
3. Whether the complainant is eligible to get relief as prayed for partly or fully.

Decision with reasons

            All the points are taken together as they are interlaced.

            After scrutinizing vividly the complaint, written version , evidence of both sides, and all other documents brought before this Forum by both the parties and hearing argument from the Ld. Advocates of both sides it appears that admittedly the father of the complainant had taken an insurance policy with coverage of 3 lacs sicne 3.10.2013 to 4.10.2014 and the family members were also the insured under the said policy.

            It is admitted fact that during the policy period complainant felt back-pain and accordingly he visited with the concerned medical practitioner on 9.4.2014 and as per advice of the doctor, complainant  was admitted to park Clinic and he underwent Kyphosis correction Surgery  on 29.4.2014 and was discharged from the said Nursing Home on 6.5.2014 and complainant has to spend an amount of Rs.5,18,111/- only.

             The crux of the case is that whether the repudiation of the claim in question on the ground of pre-existing disease by the Insurer/O.P  is reasonable or not and to decide that following discussion is advanced. It is fact that the concerned Medical Practitioner  had mentioned in the discharge certificate dated 6.4.2014  “gradually progressive deformity of back-12 months” and afterwards instead of 12 months it was mentioned by the Park Clinic Authority with an explanation that the aforesaid mistake which was made by Dr. Saumyajit Basu on 24.7.2014 was inadvertently mentioned as six months. Here it is needed to be mentioned that O.P Insurer has raised a point that rectification specifically suffering of the patient in question from 12 months to six months by the concerned medical practitioner is intentional, and afterthought and incorrect.

            In this regard, Ld. Advocate for the O.Ps has cited A medical journal from where it reveals that such operation which was undertaken by the concerned Surgeon may require at least after a year and the O.P repudiated the claim of the complainant on the ground of pre-existing disease. In this regard, a question is raised in our mind whether the father of the complainant i.e. the insured/consumer has prior knowledge about the disease in question of his son. But after going through vividly the entire record and hearing minutely arguments advanced by both sides  we find that O.Ps miserably failed to establish even through a scrap of paper ,which may be any prescription or any medical document, from where it could be established that it was within the knowledge of the father of the complainant prior to the date of policy in question.

            In this circumstances, keeping in mind the remarkable judgment of Hon’ble National Commission reported in III (2014)  that unless there is a prolong hospitalization of the patient in question of repudiation of claim on the ground of “pre-existing disease” should not be considered as justified ,if so determined by the Insurer and repudiation of claim on the ground of pre-existing disease is not reasonable and O.Ps/insurer are liable to pay the claim amount and also compensate for the mental agony and physical harassment, financial loss of the complainant/consumer/insured even after taking mediclaim policy for hassle free and tension free treatment of the insured as and when required.

            In light of the above discussion and considering the observation of the Hon’ble National Commission in III (2014) CPJ 340 (NC) ( in the case of New India Assurance Co. Vs. Rakesh Kumar) we have no hesitation to hold that as the O.Ps/Insurer have miserably failed about the prior knowledge of the father of the complainant/insured regarding  the disease in question of the complainant, the repudiation of the mediclaim in question of the insured by the insurer amounts to deficiency in rendering services of the O.Ps/Insurer towards the complainant/beneficiary consumer and also to the insured/father of the complainant. In this regard this should be mentioned here that mere assertion is not suffice to say that complainant’s disease was a pre-existing disease and if we accept the contents of the insurer/O.P then the dark days of the consumer/insured will be spread out and thereby this type of insurance company will get more money from the poor consumer with the assurance to give medical assistance as and when required and thus                                              we strongly opined that repudiation of the claim of the insured/complainant is not justified and O.Ps are duty bound to pay the claim amount of Rs.3 lac to the father of the complainant as complainant is minor son of the insured and it is beyond doubt that the aforesaid acts of the O.Ps should be determined as deficiency in rendering services which has caused tremendous mental agony, financial loss and harassment even after paying premium in question regularly for having benefit of mediclaim to be tension free if medical treatment of the insured is so required and the O.Ps are liable to aptly compensate the father of the complainant for the aforesaid reasons.

            `Thus the case succeeds.

            Hence,

                                                                        Ordered

That the case be and the same is allowed on contest against the O.Ps.

The O.Ps are directed to pay the claim amount of Rs.3 lacs(Rupees Three lacs)  along with interest @15% p.a  from 7.6.2014 , date of repudiation of the claim by O.Ps, till its realization along with cost of Rs.5000/- to the complainant within 30 days  from the date of this order.

Let a plain copy of judgment be supplied to the parties free of cost as per rule.

 

Member                                   Member                                                                       President

 

 

Dictated and corrected by me

 

 

            Member

 

 

 

 

 

 

 

 

 

 

 

 

 

The judgment in separate sheet is ready and is delivered in open Forum. As it is ,

 

Ordered

That the case be and the same is allowed on contest against the O.Ps.

The O.Ps are directed to pay the claim amount of Rs.3 lacs(Rupees Three lacs)  along with interest @15% p.a  from 7.6.2014 , date of repudiation of the claim by O.Ps, till its realization along with cost of Rs.5000/- to the complainant within 30 days  from the date of this order.

Let a plain copy of judgment be supplied to the parties free of cost as per rule.

 

Member                                   Member                                                                       President