For the Complainant -Mrs. Debjani Banerjee, Advocate
For the OPs - Mr. Ashis Chakraborty, Advocate
FINAL ORDER/JUDGEMENT
SHRI SWAPAN KUMAR MAHANTY, PRESIDENT
This is an application u/s.12 of the C.P. Act, 1986.
The brief facts of the case are that the complainant obtained Family Health Optima Insurance Plan being No. P-190000/01/2017/00/008648 from the OPs Star Health and Allied Insurance Co. Ltd. and the said policy was valid for the period from 17.10.2016 to 16.10.2017. During subsistence of the policy Smt. Mukta Pal, W/o of the complainant was admitted to Medica Super specialty Hospital on 18.09.2017 with severe abdominal pain. Insured was discharged on 23.09.2017 and the complainant submitted claim of Rs. 60,389/- for reimbursement against claim No. 0315040. The OP paid Rs. 34,733/- out of total claim. After receiving payment of the above referred amount of Rs. 34,733/- from the insurer, the complainant sent a letter dated 16.11.2017 to the insurer seeking for payment of balance amount of Rs. 25,656/-. There is deficiency in service on the part of the OPs. Hence, the consumer complaint.
The OPs have contested the case by filing a joint Written Version contending inter alia that the complainant obtained a Family Health Insurance Policy being No. P-190000/01/2017/00/008648 from the OPs and the said policy was valid for the period from 17.10.2016 to 16.10.2017. The insured was admitted to Medica Super specialty Hospital on 18.09.2017 and submitted a claim form along with medical documents for reimbursement of medical expenses. OPs proceeded the claim and paid Rs. 34,733/- for UTI. The insured had “Hysterectomy” 15 years back and such fact was not disclosed at the time of porting the policy. Hence, the insurer disallowed the remaining part of claim of reimbursement. Rights & liabilities of Insured and Insurer are strictly governed by Insurance Policy. No exception or relaxation can be made on the ground of equity. Accordingly, the OPs have prayed for dismissal of the consumer complaint.
On the pleadings of the parties the following points necessarily came up for determination.
- Whether the complainant had a Family Health Optima Insurance Policy being No. P-190000/01/2017/00/008648 with the OPs?
- Whether the OPs are justified to deduct Rs. 25,656/- as per terms & conditions of the policy?
- Whether there was any deficiency in service on the part of the OPs?
- Whether the complainant is entitled to get balance reimbursement amount of Rs. 25,656/-, compensation and litigation cost?
Decision with Reasons
Point Nos. 1 to 4 :-
All the points are taken up together for the sake of convenience and brevity in discussion.
Both parties have tendered evidence through affidavit. They have also given reply against the questionnaire set forth by their adversaries. Both parties have also filed their BNAs.
We have gone through the evidence coupled with documents on record.
Fact remains that the complainant obtained a Family Health Optima Insurance Policy being No. P-190000/01/2017/00/008648 for the period from 17.10.2016 to midnight of 16.10.2017. It is also true that wife of the complainant was admitted to Medica Super specialty Hospital on 18.09.2017 with history of abdomen pain and increased stool frequency during subsisting of Family Health Optima Insurance Policy. There is also no dispute that wife of the complainant was discharged on 23.07.2017 and the complainant lodged claim being No. 0315040 of Rs. 60,389/- for reimbursement. The Insurer settled the claim to the extent of Rs. 34,733/- and disallowed the remaining claim of reimbursement . Hence, the complainant directed the OPs to pay remaining part of claim amount.
On the contrary, the plea of the OPs is that the insured Smt. Mukta Pal had “hysterectomy” 15 years back and such fact was not disclosed at the time of porting of the policy. Thus, the insurer disallowed the remaining claim of reimbursement.
On bare perusal of the photocopy of insurance policy it appears that pre-existing disease claim of the insured Mukta Pal is not covered under the policy . Pre-existing disease means any condition, aliment or injury or related condition (s) for which the insured person had signs or symptoms, and/ or were diagnosed, and/ or received medical advice/treatment within 48 months prior to the insured person’s first policy with any Indian insurer. It is apparent from the proposal Form of Mediclaim Policy under the head ”Health History” we find that proposar Shri Arup Pal wrote “No” in respect of column Nos. 2 to 11. Photocopy of Discharge Summary of the insured goes to show that her uterus was partially operated with normal residual cervix and fatty liver. According to the Mediclaim Policy insured is not covered pre-existing disease and the proposer suppressed the material facts of surgery of “hysterectomy” of the insured prior to port of the policy. The discharge summary itself established the pre-existing condition.
Practically, the OPs allowed room rent, professional fees of doctor, investigation & diagnostics expenditure and medicines in part after proportionate deduction of total claim and remitted Rs. 34,733/- to the account of the complainant for treatment of the insured. The OPs were justified to deduct proportionate amount of claim of the insured Mukta Pal under terms & conditions of the Mediclaim Policy. Rights and liabilities of the insured and insurer are strictly governed by the Insurance Policy. No exception or relaxation can be made on the ground of equity. In Anshupati Fibres Pvt. Ltd. –Vs- National Insurance Co. Ltd. & Another (CC No. 32 of 2007) decided on 14.01.2015 the Hon’ble NCDRC has been pleased to observe that once the insured accepts a particular amount in full and final settlement of his claim, he is stopped from claiming any further amount from the Insurance company, since the settlement constitutes a binding contract between the parties unless it is shown that it was influenced by use of coercision, undue influence, fraud, mistake or misrepresentation. In the instant case, no such influencing factor has been established by the complainant. In our opinion, there was no laches and/or deficiency in service on the part of OPs for disallowing full claim of the complainant. Thus, the complainant is not entitled to get any relief as prayed for. Accordingly, all the points under determination are decided.
In result, the complaint fails.
Hence,
Ordered
That the complaint case be and the same is dismissed on contest against the OPs. However, there shall be no order as to cost.
