Date of filing: 16.03.2016 Date of disposal: 10.07.2018
Complainant: Sri Jiban Chaudhuri, S/o. Dhirendranath Chaudhuri, resident of Gushkara Purbasa Pally, PO: Gushkara, PS: Ausgram, District: Burdwan, PIN – 713 128.
- V E R S U S -
Opposite Party: 1. The Manager, Medicare TPA Service (I) Pvt. Ltd., 6B, Bishop Lefroy Road, Kolkata – 700 020.
2. The Manager (L.I.C.I.), Life Insurance Company, Decode: H046 Jeevan Prakash, G. T. Road (West End), Asansole, District: Burdwan, West Bengal, PIN – 713 304.
3. The Manager (L.I.C.I.), Burdwan Divisional Office, Ghordur Chati, Barddhaman, PO: Sripally, PS. & Dist: Burdwan, PIN – 713 103.
4. The Asst. Administrative Officer, LICI Ghuskara Branch, Ghuskara, PO: Ghuskara, PS: Ausgram, District: Burdwan, PIN – 713 128.
Present:
Hon’ble President: Smt. Jayanti Maitra (Ray).
Hon’ble Member: Smt. Nivedita Ghosh.
Hon’ble Member: Dr. Tapan Kumar Tripathy.
Appeared for the Complainant: Ld. Advocate, Ashish Kr. Paul.
Appeared for the Opposite Party No. 1: None (ex parte).
Appeared for the Opposite Party No. 2, 3 & 4: Ld. Advocate, Saurabh De.
J U D G E M E N T
This complaint is filed by the complainant u/S. 12 of the C. P. Act, 1986 against the Ops as the Ops have repudiated his legitimate mediclaim.
The case of the complainant in brief is that the complainant is a consumer under the OP-1 as well as OP No. 2, 3 & 4 by commencement of a policy, namely, LIC’s Health Protection Plus Conditions and Privileges, Table No. 902 vide No. 468824851 on 10.02.2010 and the benefit which has been mentioned in the certificate and paid EMI regularly. That the complainant after his medical treatment in the institution of Fortis Hospital, Kolkata – 700 107 applied for getting the benefit from the OP-1 for the major surgical, but is unfortunate that the Ops have denied to pay the health benefit, by showing the hidden weapon as stated in the repudiation letter dated 31.03.2015 & 11.04.2015. the OP-1 & 4 by giving letter dated 31.03.2015 & 11.04.2015 denied to pay the benefit of the claim and thereafter the complainant sent lawyer’s notice to the OP-1&2 but the OP-1 did not reply and the OP-2 shifted his responsibility to the OP-3 by giving letter to the Lawyer on 18.09.2015 and OP-3 by accepting the burden has given the answer to the legal notice on 19.10.2015 by doing confirmation to OP-1&4. The complainant several times knocked the door of the Ops to get his valid claim in accordance with the provisions of the policy but the same has been repudiated with ulterior motive. At the act or omission of the Ops the complainant being the consumer of the Ops suffered mental pain and agony. Finding no other alternative the complainant filed this complaint for giving direction to the Op[s to pay Rs. 3,04,500=00 towards expenditure for his treatment at Fortis Hospital with interest since 31.03.2015, the date of repudiation till date of payment along with Rs.5,00,000=00 as compensation for mental pain and agony and Rs. 20,000=00 as litigation cost.
After admission summons were issued to all the Ops. But the OP-1 after receiving the said notice did not appear to contest the case nor filed any written version against the petition of complaint filed by the complainant. Therefore the case is heard ex parte against the OP-1.
The complaint has been contested by the OP-2, 3 & 4 by filing conjoint written version denying all the material allegations made by the complainant in his petition of complaint. The case of the OP-2 to 4 is that the complainant took policy with annual premium 15,000=00 having health insurance coverage of his family which covers initial daily Hospital Cash Benefit (HCB) of Rs. 1500/- and Maximum Major Surgical (MCB) Benefit sum assured of Rs. 3, 00,000/- for the principal insured subject to fulfillment of conditions and privileges of the policy. It is found from the documents submitted by the complainant that the complainant took admission in Fortis Hospital on 06.11.2014 and after staying there for three days he was discharged on 08.11.2014 and as such no hospital cash benefit (HCB) was allowed for first two days and as such the complainant was entitled for hospital cash benefit of Rs. 1875/- The complainant claimed Rs. 4500 for HCB and Rs. 3,00,000/- for MCB for reimbursement of medical expenses for availing medical treatment of three days. After scrutiny of documents by the T.P.A. it is found from the discharge summary dated 08.11.2014 that after Angiogram done on 06.11.2014 it was diagnosed Single Vessel Coronary Artery Disease and the complainant had undergone PTCA with Stent to LAD on the same day. The Single Vessel Coronary Angioplasty is not included in the list of allowed surgeries bearing Nos. 1 to 49 as mentioned in Conditions and Privileges of the policy. As per conditions and privileges of this policy it covers only 40% of sum assured of Rs. 3,00,000/- i.e. Rs. 1,20,000=00 towards reimbursement of Coronary Angioplasty with Stent Implantation (Two or more coronary arteries must be stented). But in this case the complainant underwent Single Vessel Coronary Angioplasty and a single stent was implanted.
These Ops further submit that the complainant availed medical treatment from Apollo Hospitals, Chennai in the year 2008 for his Bladder tumour which is two years prior to the date of commencement of this policy and as per pathological report dated 31.05.2008 issued by Apollo Hospitals, Chennai, the complainant was a patient or carcinoma which has been reflected in the discharge summary dated 08.11.2014 issued by the Forties Hospital Limited, Kolkata. But at the time of taking the said policy the complainant did not disclose it in his proposal form. Thus in view of the above as per conditions and privileges of the above policy in question, under Item No. 6: Exclusions (I) Exclusion applicable to Hospital Cash Benefit and (II) Exclusions applicable to Major surgical Benefits, the TPA, Medicare TPA Services (I) Pvt. Ltd., this Forum has no alternative but to reject the claim for suppression of material facts and for non-disclosure of pre-existing disease of Carcinoma with Bladder tumour in his proposal form at the time of taking the policy on 10.02.2010.
These Ops further submit that there has not been any deficiency in service, negligence and unfair trade practice on the part of these Ops and as such the instant complaint is liable to be summarily dismissed with cost.
To prove the case the complainant has filed his evidence on affidavit stating the facts of this case with the prayer as stated above. OP also prayed for treating the written version filed by the OP-2, 3 & 4 as their evidence. The written version is also supported by affidavit and OP-1 though filed written version but subsequently failed to contest the case. Therefore, the case is heard ex parte against the OP-01. OP-2, 3 & 4 also filed written argument along with supportive documents.
From the evidence of both sides, as well as, documents filed by the parties it is not denied that the complainant purchased LIC’s Health Protection Plus policy and he has been paying the premiums of the policy since purchase regularly. Complainant also filed documents showing that during subsistence of the policy he undergone treatment in Fortis Hospital. The discharge summary of the Fortis hospital goes to show that he was admitted for Coronary Angiogram which was done on 06.11.2014 and it revealed Single Vessel Coronary Artery Disease. He was undergone PTCA with stent to with stenting of LAD and was discharged on 08.11.2014. In the said discharge summary he was diagnosed as known hypertensive and had past history of Chemotherapy for papillary transitional cell CA of urinary bladder.
As the OP rejected the claim of the complainant on the ground of H01 pre-existing illness irrespective of prior medical treatment or advise and also on the ground of M02 pre-existing illness irrespective of prior medical treatment or advise that he underwent treatment for CA Bladder on 30.05.2008 which is pre-existing. The policy inception date was 10.02.1010 and as per policy condition any disease related or unrelated to presenting ailment is not payable. So the claim of the complainant was rejected/repudiated under Clause H01, M02.
OP put questionnaires to the evidence of the complainant specifically to which the complainant replied in negative. Whether he was taking regularly any medicine during first five years to which he also replied in negative. He specifically denied that he was suffering from any illness, disorder, disability during first five years. Also OP put questions whether he was suffering from any cancer for any kind, to which the complainant also replied in the negative. He did not disclose this fact of earlier sufferings and treatment in the proposal form and thereby conceal the fact. The complainant during argument stated that OP put double question and confusing questions regarding his previous ailments or previous treatment so he could not understand the question and replied in the negative. Therefore OP argued that concealment of medical history by complainant is deliberate and actually wrong information provided by insured has been established by producing the documents of his earlier history of treatment in the Apollo Hospital where he was admitted on 29.05.2008 and discharged on 01.06.2008. He was diagnosed Bladder Tumour Post – Mytomycin C and Surgery Cystoscopy + TURBT. In the discharge summary of Apollo Hospital dated 30.05.2008 was also filed by the OP- 2, 3 & 4. In the written version OP took another ground of refusal that complainant was diagnosed with Single Vessel Coronary Artery Disease and this Single Vessel Coronary Angioplasty is not included in the list of alleged surgeries bearing No. 1 to 49 as mentioned in the conditions and privileges of the policy papers under the head ‘surgical benefit’ annexure, that two or more coronary arteries must be stented. But complainant had undergone only Single Vessel Coronary Angioplasty where on the strength of conditions and privileges of the policy, limited reimbursement is eligible for at least two or more coronary Angioplasty. But this ground of rejection, that it is not listed on alleged surgeries bearing No. 1 to 49, has not been taken in the letter of repudiation to the complainant dated 31.03.2015. Rather the ground of repudiation was pre-existing illness.
Therefore, OP-2, 3 & 4 have been able to prove by sufficient documentary evidence that there is a suppression of pre-existing disease by the complainant which is a violation of policy condition. Therefore, the OP-2, 3 & 4 repudiated the claim. Concealment of such medical history and deliberate wrong information by the insured has been established and we do not find any deficiency in service on the part of the OP- 2, 3 & 4 in repudiating such claim. OP-2, 3 & 4 relied on the judgement passed by the Hon’ble NCDRC as reported in 2016 (1) CPJ 57. Therefore, the complainant is not entitled to get any benefit as prayed for. C.F. paid is correct.
Hence, it is
O r d e r e d
that the Consumer Complaint being No. 39/2016 be and the same is dismissed ex parte against the OP-1 without any cost and dismissed on contest against the OP-2, 3 & 4 without any cost.
Let plain copies of this order be supplied to the parties free of cost as per provisions of law.
Dictated & Corrected by me: (Jayanti Maitra (Ray)
President
(Jayanti Maitra (Ray) DCDRF, Burdwan
President
DCDRF, Burdwan
(Tapan Kumar Tripathy) (Nivedita Ghosh)
Member Member
DCDRF, Burdwan DCDRF, Burdwan
