In the District Consumer Disputes Redressal Forum, Murshidabad

Berhampore, Murshidabad.

Case No. CC/92 /2014

Date of filing: 07/03/2014                                                                                             Date of Final Order:    27/07/2016

Ajmat Haque.

S/O.- Rasul Box.

Vill.- Kaitha. P.O.- Sundarpur.

P.S.-Burwan.Dist- Murshidabad.     ……………………………...Complainant                                                                       

- Vs-

 The  Manager,

 Reliance Life Insurance Co. Ltd.

 Berhampore Branch,3/20, K.K. Banerjee Road, 3 rd Floor,

 P.O.& P.S.- Berhampore.Dist.- Murshidabad.PIN.-742101. …………….……….  Opposite Party

                          Before:      Hon’ble President, Anupam Bhattacharyya.

                                             Hon’ble Member, Samaresh Kumar Mitra.

                                             Hon’ble Member, Pranati Ali.

FINAL ORDER

Samaresh Kumar Mitra, Member.

             This complaint has been filed by the complainant u/s 12 of C.P. Act, 1986 praying for an order upon the OP to pay a sum of Rs.1,01,767 as major surgical benefit and also a sum of Rs.2000/- for cost and to pay further a sum of Rs.10,000/- for compensation and to pass such other order or orders as the Forum would deem fit and proper.

                The case of the complainant, in brief, is that he took a policy being No. 16772996 under Reliance Traditional Super Invest Assure Plan with a sum assured of Rs.1, 01,767/- on 31.03.2010 for term of 15 year. The complainant paid the premium. The policy was renewed on 31.03.2011. During the validity of the policy the complainant became ill due ti bilateral Renal Calculi Protatomegaly which was detected on 01.10.2012 in Manipal Hospital at Bangalore. He underwent operation on 07.10.12 there. He was discharged therefrom on 08.10.2012 and had to undergo several tests at the said Hospital. The complainant had to spend a sum of Rs.1, 01,767/- for his treatment at Manipal Hospital from 04.10.12 to 08.12.12. The complainant came up with the Claim Form before the OP Company on 18.02.2013 for payment but the OP did not settle his claim. The complainant is entitled to get his claim as per terms and conditions of the Policy but the OP failed to disburse the said amount which is tantamount to deficiency in service on the part of the OP Company. Being aggrieved by the dealings of the OP Company, the complainant knocked the door of the Forum by filing this case. Hence, the complaint case.

                The case of the OP, in brief, is that all the allegations made in different paragraphs by the complainant in his complaint are false and fabricated and not tenable in law.  The case of the OP is that the complainant concealed the material facts before taking the policy. His claim was repudiated on 30.11.2013. It is true that the complainant had opted for a “Reliance Traditional Super Invest Assure Plan on 31.03.2010 with a sum assured amount of Rs.1, 79, 1745/- for a period of 15 year. The policy contains a list of all the Major Surgical Benefit wherein the Policy Holders are entitled to get reimbursement. The disease for which the complainant was diagnosed and operated upon does not come within the ambit of listed surgeries as per Major Surgical Benefit attached with the policy. Therefore, the claim of the complainant was repudiated and the matter has been intimated to him vide letter 30.11.2013 through registered post. The OP has no deficiency in service. The OP prays for dismissing the complaint of the complainant with cost.

  The complainant filed evidence on affidavit which is nothing but replica of complaint petition.

Argument as advanced by the agent of the opposite parties heard in full.

From the discussion herein above, we find the following Issues/Points for consideration.

ISSUES/POINTS   FOR   CONSIDERATION

 1. Whether the Complainant Ajmat Haque ‘Consumer’ of the opposite party?

 2. Whether this Forum has territorial/pecuniary jurisdiction to entertain and try the case?

 3. Whether the O.Ps carried on unfair trade practice/rendered any deficiency in service towards the Complainant?

4.   Whether the complainants proved their case against the opposite party, as alleged and whether the opposite party is liable for compensation to them?

DECISION WITH REASONS

   In the light of discussions here in above we find that the issues/points should be decided based on the above perspectives.

(1).Whether the Complainant Ajmat Haque ‘Consumer’ of the opposite party?

                    From the materials on record it is transparent that the Complainant is a “Consumer” as provided by the spirit of section 2(1)(d)(ii) of the Consumer Protection Act,1986.The complainant herein is the consumer of the OP, as policy holder insured his life through medical insurance and OP is the insurer.

(2).Whether this Forum has territorial/pecuniary jurisdiction to entertain and try the case?

         Both the complainant and opposite parties are residents/carrying on business within the district of Murshidabad. The complaint valued Rs.1,01,767/-  as medical expenditure in the course of treatment  of the complainant and Rs.10,000/-as compensation for mental agony and  Rs.2000/- as cost ad valorem which is within Rs.20,00,000/- limit of this Forum. So, this Forum has territorial/pecuniary jurisdiction to entertain and try the case.   

 (3).Whether the opposite party carried on Unfair Trade Practice/rendered any deficiency in service towards the Complainant?

           It is well settled proposition of law that a contract of insurance is based on the principles of utmost good faith-uberrimae fidei, applicable to both the parties. The rule of nondisclosure of material facts vitiating a policy still holds the field. The bargaining position of the parties in a contract of insurance is unequal. The insured knows all the facts; the insurer is unaware of anything which may be material to the risk. Very often, it is the insured who is the sole person who has this knowledge. The insurer may not even have the means to find out facts which would materially affect the risk. The law, therefore, enjoins on the insured an absolute duty to disclose correctly all material facts which is within his/her personal knowledge or which he ought to have known had he made reasonable inquiries. A contract of insurance, therefore, can be repudiated for non disclosure of material facts.

       The case of the complainant is that he being the policyholder of OP insurance company treated before Manipal Hospital, Bangalore as he was suffering from Bilateral Renal Calculi Prostatomegaly and operated there as an indoor patient. Thereafter he submitted claim Form before the OP who in his turn did not settle the claim of the complainant. Getting no alternative he filed the instant complaint before this Forum for redressal.

     The sole OP in his written version assailed that the complainant concealed the material facts before taking the policy. His claim was repudiated on 30.11.2013. It is true that the complainant had opted for a “Reliance Traditional Super Invest Assure Plan on 31.03.2010 with a sum assured amount of Rs.1,79, 1745/- for a period of 15 years. The policy contains a list of all the Major Surgical Benefit wherein the Policy Holders are entitled to get reimbursement. The disease for which the complainant was diagnosed and operated upon does not come within the ambit of listed surgeries as per Major Surgical Benefit attached with the policy. The OP has no deficiency in service. The OP prays for dismissing the complaint of the complainant with cost.

      It appears from the list of Surgery description as reflected in the Reliance New Major Surgical Benefit Rider of OP the location of surgery is Kidney but in the head of surgery description it is Kidney Transplant for complete Renal failure and the benefit is 75% of sum assured. In the benefit structure; for each surgery performed, the lump sum which is expressed as a percentage of the Reliance New Major Surgical Benefit Rider sum assured in the surgery list, is only granted for any surgery listed in the applicable surgery list subject to satisfactory document evidence regarding the medical need for and completion of the performed surgery. Any one life could not claim for the same surgery more than once and this would be across all policies held by the life with Reliance Life Insurance Company Limited.

      The documents that submitted by the complainant transpires that the complainant is a policyholder of OP insurance company. He opted for Reliance Life Insurance Policy for a period 15 yrs. The complainant was diagnosed with Bilateral Renal Calculi and he underwent surgery in Manipal Hospital, Bangalore. Then he submitted his claim Form for reimbursement of medical expenses incurred by him. As the disease for which the complainant was diagnosed and operated upon does not come within the ambit of listed surgeries as per Major Surgical Benefit attached with the policy, so the claim of the complainant was repudiated and it was intimated to the complainant.

      On a careful reading we find from the treatment summary that the patient/complainant was suffering from Bilateral Renal Calculi with no Hydronephrosis & Mild Prostatomegaly. The said disease for which the complainant underwent surgery does not fall in the listed surgeries as per Major Surgical Benefit Rider in the policy.

      The burden of proof lies on the complainant that the surgery which he underwent at Manipal Hospital, Bangalore covered under the policy of OP by which he is covered. But he could not produce even the policy document from which we can infer that this surgery is covered or not. Not a scrap of paper has been filed by the complainant to discard the allegations leveled against him in the written version as filed by the OP.

       We do not find merit in the above contention. It is well settled that insurance is in the nature of a contract and it has to be strictly implemented without adding or deleting any words to the agreement arrived at between the parties. Therefore by strict application of the insurance contract the expenses incurred on the aforesaid disease by the complainant are not covered under the Reliance New Major Surgical Benefit Rider. Thus in our view the repudiation of the claim of this complainant by the OP is justified.

      From the above discussion and careful observation of documents as produced by the parties we are in a opinion that the surgery that underwent for the disease of the complainant does not fall in the list of surgery description as produced by the OP so the claim of the complainant is rightly repudiated by the OP.   

4. Whether the complainant proved his case against the opposite party, as alleged and whether the opposite party is liable for compensation to him?

                    The discussion made herein before, we have no hesitation to come in a conclusion that the Complainant could not able to prove his case and the Opposite Party is not liable to pay the amount that incurred during the surgery of this complainant and any compensation.

ORDER

                    Hence, it is ordered that the complaint case being No.92/2014 be and the same is dismissed on merit with no order as to cost against the Opposite party.

                    The OP in exonerated from his liability of paying any compensation to this complaint.

                   No other reliefs are awarded to the complainant for harassment and mental agony.

                 Let a plain copy of this Order be supplied free of cost to the parties/their Ld. Advocates/Agents on record by hand under proper acknowledgement/ sent by ordinary Post for information & necessary action.

   Dictated and corrected by me.

                  Member,                                                    Member,                                            President,

 District Consumer Disputes               District Consumer Disputes                      District Consumer Disputes          Redressal Forum, Murshidabad.      Redressal Forum, Murshidabad.           Redressal Forum, Murshidabad.