In the Court of the
Consumer Disputes Redressal Forum, Unit -I, Kolkata,
8B, Nelie Sengupta Sarani, Kolkata-700087.
CDF/Unit-I/Case No. 235 / 2010.
1) Sri Shyamal Kumar Bandyopadhyay,
11A, Birpara Lane, Ghugu Dangha, Kolkata-130. ---------- Complainant
---Versus---
1) The Manager / Authorized person representing
M/s. Royal Sundaram Alliance Insurance Co. Ltd.,
Sundaram Tower, 45 & 46, Whites Road, Chennai-600014.
2) The Manager / Authorized Officer representing
M/s. Royal Sundaram Alliance Insurance Co. Ltd.,
Kolkata Office, Flat No. 2, Paul Mansions,
6, Bishop Lefroy Road, Kolkata-700020.
3) The Manager / Authorized Officer representing
Medicare TPA Services (I) Pvt. Ltd.
2, Paul Mansions, 6, Bishop Lefroy Road, Kolkata-20. ---------- Opposite Parties
Present : Sri Sankar Nath Das, President.
Smt. Jhumki Saha, Member.
Dr. A. B. Chakraborty, Member
Order No. 1 7 Dated 1 3 / 0 1 / 2 0 1 1 .
The petition of complaint u/s 12 of the C.P. Act, 1986 has been filed by Sri Shyamal Kr. Bandopadhyay against Royal Sundaram Alliance Insurance Co. and others. The case of the complainant in short is that he purchased a Health Shield Insurance from o.p. no.1 vide certificate no.HE 00102071000100 Master Policy no.HLST CB 0030 for the period from 25.1.07 to 24.1.09 by paying a total amount of Rs.7205/- including TPA fees, service tax, educational cess (net premium being Rs.5971/- for a sum insured Rs.1,50,000/-) and that the policy is still continued vide o.p. company letter dt.27.1.09 for the period from 25.1.09 to 24.1.11 by paying Rs.8284/-. And on 9.3.09 complainant fell sick and on 12.3.09 he was admitted to B.M. Birla Heart Research Centre for heart problem and he was treated there from 12.3.09 to 27.3.09 ad discharged on 27.3.09 and the cost of such CAPG operation was Rs.1,50,000/- as per package. However, the total expenditure stood Rs.1,61,932/- and it was within the valid policy period and the complainant submitted the claim with all relevant papers on 15.4.09 and complainant did not receive the said claim and o.p. company repudiated the claim on the plea “pre-existing disease” vide letter issued by o.p. no.1 dt.1.7.09. Hence the instant case.
O.ps. had entered 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 as well as evidence and the documents lying with record and the policy in particular and we find that the policy was valid during the claim period. It is natural justice and settled principle of law that an insurance company cannot deny medical claim on the ground of concealment of pre-existing diseases in the event of hospitalization and undergoing surgery of the consumer. Especially when the consumer was not a defaulter and policy was very much valid during the relevant period. That being the position we are of the view that there is a clear deficiency on the part of the o.ps. being a service provider to a consumer / complainant and complainant is entitled to relief as prayed for.
Hence, ordered,
That the petition of complaint is allowed on contest with cost against the o.ps. O.ps. are directed tom pay a sum of Rs.1,61,932/- (Rupees one lakh sixty one thousand nine hundred thirty two) only together with interest @ 9% p.a. till the date of realization from the date of claim. O.ps. are further directed to pay compensation of rs.15,000/- (Rupees fifteen thousand) only for harassment and mental agony and litigation cost of Rs.1000/- (Rupees one thousand) only. O.ps. are jointly and severally directed to pay the entire so awarded sum to the complainant within 45 days from the date of communication of this order, i.e. an interest @ 9% p.a. shall accrue over the entire sum due to the credit of the complainant till the date of realization.
Supply certified copy of this order to the parties.
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MEMBER MEMBER PRESIDENT
