IN THE COURT OF THE LD. DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT S I L I G U R I.

CONSUMER CASE NO. : 65/S/2015.                              DATED : 21.07.2017.   

BEFORE  PRESIDENT              : SMT. KRISHNA PODDAR,

                                                              President, D.C.D.R.F., Siliguri.

                      MEMBER                : SMT. PRATITI BHATTACHARYYA.

COMPLAINANT             : SRI PARTHA SARATHI SAHA,

  Rathkhola,  P.O.- Rabindra Sarani,  

  Siliguri, Dist.- Darjeeling.

  Mob. No.98320 64224.   

O.P.                                           : THE MANAGER,

   The Oriental Insurance Company Limited,

   Malhotra Tower, Hill Cart Road,  

   Pradhan Nagar, Siliguri - 734 003. 

FOR THE COMPLAINANT         : Sri Sanat Sev Sarkar, Advocate.

J U D G E M E N T

Smt. Krishna Poddar, Ld. President.

Brief facts of the case are that the complainant is the holder of two mediclaim policy (individuals) being Nos.313205/48/2013/960 with effect from 27.10.12 to 26.10.13 and 313205/48/2013/907 with effect from 27.10.13 to 26.10.14 and sum insured in each policy is Rs.1,25,000/- (for self).  The OP insurance company issued policy certificates to the complainant after receiving premium as per terms and conditions of the mediclaim policy.  During the period of first policy, the complainant fell ill and hospitalized on 24.10.2013 and thereafter again hospitalized on 14.11.2013 and 20.11.2013 to 22.11.2013 within the second policy period.  Thereafter, the complainant made claim on 07.01.2014 and 10.02.2014 respectively to the OP, but the OP allowed award for the first policy a sum of Rs.75,000/- but repudiated the second claim by letter dated 18.11.2014 showing that as per clause No.3.17 of the mediclaim policy which read as “Anyone illness will be deemed to mean continuous period of illness and it includes relapse within 105 days from the date of discharges from hospital/nursing home from where the treatment was taken.  Occurrence of the same illness after a lapse of 105 days as stated above will be considered as fresh illness for the purpose of this policy”. 

In the said letter the OP had mentioned the policy no.313205/48/2014/907 but it appears that OP has granted award for the policy no.313205/48/2013/960 the sum of Rs.75,000/- but rejected/repudiated claim in respect of the policy

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No.313205/48/2014/907 which is completely separate one and earlier to the claim awarded by the OP.  The complainant refused to take the cheque amounting to Rs.75,000/- as the OP tried to merge the both claims as a single one.  As per the said policy the complainant has claimed the sum of Rs.1,25,000/- although his total medical expenses was incurred more than the assured amount.  It is required to mention that the diseases are separate as well as policy and accordingly OP is bound to pay the compensation as prayed by the complainant.  Getting no other alternative the complainant sent a notice to the OP through his engaged lawyer vide letter dated 16.04.2015 but the said notice was refused by the OP on 20.04.2015.  The OP illegally and arbitrarily repudiated the claim of the complainant and did not discharge his duties and for non payment of medical expenses within time the complainant sustained mental agony and pain.  Accordingly, the complainant has filed the instant case with a prayer to direct the OP to pay medical expenses to the tune of Rs.2,00,000/- i.e., Rs.1,25,000/- only for the policy No.313205/48/2014/907 and Rs.75,000/- for the policy No.313205/48/2013/960 out of the total expenses of Rs.5,00,000/- together with interest @ 15 % per annum upto the payment and further a sum of Rs.50,000/- towards compensation for mental agony, harassment and a sum of Rs.5,000/- towards litigation cost. 

OP entered appearance and contested the case by filing written version wherein the material averments made in the complaint are denied and it has been contented inter-alia that the present case is not maintainable.  It has been stated by the OP that one heart related claim was preferred by the complainant under Policy No.313205/48/2013/960 period of insurance 27.10.12 to 26.10.13 for hospitalization period from 26.10.113 to 01.11.13.  The complainant got admitted on the last day of the policy i.e., on 26.10.2013 and the policy was renewed on 27.10.2013.  Since the disease was pre-existing from 2008, the claim was settled by the OP insurance company for Rs.75,000/- i.e., previous sum insured and total sum insured was paid and no balance left.  The complainant again fell sick for the same type of disease as he was earlier treated (heart ailment disease) and was admitted to hospital for the second time on 14.11.2013 i.e., after 14 days from the date of discharge of last hospitalization and lodged another claim for that.  This falls under “Anyone illness” clause as defined in individual mediclaim policy clause No.3.17 which reads as “Anyone illness : will be deemed to mean continuous period of illness and it includes relapses within 105 days from the date of discharge from the hospital/nursing home from where the treatment was taken.  Occurrence of the same illness after a lapse of 105 days as stated above will be considered as fresh illness for the purpose of this policy”.  It has been further contended by the OP that

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sum of insured under policy no.313025/48/2013/960 has been fully exhausted in respect of earlier claim.  Though the complainant/insured had renewed the policy being 313205/48/2014/907 and the present claim was lodged under renewed policy, but within 14 days in respect of earlier treatment for the same type of disease, therefore the present claim falls under anyone illness clause no.3.17 under individual mediclaim policy and therefore the claim under the said policy was repudiated by issuing letter dated 18.11.2014.  It has been further contended by the OP that there is no deficiency in service on the part of the OP and the repudiation letter dated 18.11.2014 is absolutely lawful and proper showing and as such the complainant is not entitled to get any relief as claimed for and the present case is liable to be dismissed with cost.

To prove the case, the complainant has filed the following documents:-

1.       Xerox copy of Medical Policy vide No.313205/48/2014/907 w.e.f. 27.10.2013

          to 26.10.2014.

2.       Xerox copy of Medical Policy vide No.313205/48/2013/960 w.e.f. 27.10.2012

          to 26.10.2013.

3.       Xerox copy of submission of bill dt. 10.02.2014 for the policy 31325/48/

         2014/907. 

4.       Xerox copy of submission of bill dt. 07.01.14 for the policy

313205/48/2014/960. 

5.       Xerox copy of claim dated 25.10.2013.

6.       Xerox copy of claim dated 14.11.2013. 

7.       Xerox copy of Medical expenses along with discharged (5 sheets).

8.       Xerox copy of repudiated letter of insurance Co. dated 18.11.14.

9.       Xerox copy of Lawyer notice dated 16.04.15. 

10.     Xerox copy of registered envelop along with A/D duly served (refused).                                                             

OP has filed the following documents :-

A.      Individual Mediclaim Policies Schedule bearing No.313205/48/2014/907, valid from 27.10.2013 to 26.10.2014 and 313205/48/2013/960, valid from 27.10.13 to 26.10.2013 issued in the name of Mr. Partha Sarathi Saa together with Mediclaim Insurance Policy (Individuals) containing the terms, conditions, exclusions and limitations etc. 

B.      Discharge Summary dated 01.11.2013 issued by Dr. Chhang’s Super Speciality Hospital Pvt. Ltd., Siliguri in the name of Partha Sarathi Saha

C.      Coronary Angiography Report dated 14.11.2013 issued by Medica Super Speciality Hospital, Kolkata in the name of Parth Sarathi Saha. 

D.      Coronary Angioplasty (PTCA) Report dated 22.11.2013 issued by Medica Super Speciality Hospital, Kolkata in the name of Partha Sarathi Saha.

Contd.....P/4

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E.      Discharge Summary (Cardiology) dated 22.11.2013 issued by Medical Super Speciality Hospital, Kolkata in the name of Partha Sarathi Saha. 

F.       Repudiation Letter dated 18.11.2014 issued by the OP insurance company to the complainant.

          Complainant has filed evidence in-chief.

Complainant has filed written notes of argument.

          OP has filed evidence in-chief.

OP has filed Written Notes of Argument.

Points for determination

1.       Is there any deficiency in service on the part of the OP?

2.       Is the complainant entitled to get any relief as prayed for ?

Decision with reason

          Both issues are taken up together for the brevity and convenience of discussion.

 is admitted fact that the complainant obtained mediclaim policy being Nos.313205/48/2013/960 for the period from 27.10.12 to 26.10.13 and 313205/48/2013/907 for the period from 27.10.13 to 26.10.14 from the OP and sum insured in each policy was Rs.1,25,005/-.  During the period of first policy, the complainant fell ill and hospitalized on 24.10.2013 and thereafter he again hospitalized on 14.11.2013 and 20.11.13 to 22.11.13 within the second policy period and thereafter lodged claim on 07.01.2014 and 10.02.2014 to the OP but the OP allowed award for the first policy a sum of Rs.75,000/- but repudiated the claim in respect of the second policy by letter dated 18.11.2014 stating that as per clause 3.17 of mediclaim policy he is not entitled to get any award.  This is the specific case of the complainant that both the policy were separate and the disease/illness of the complainant during the policy covered period of first policy and second policy were also different disease for which he was entitled to get award as per claim.

The OP on the other hand claimed that one heart related claim was submitted by the complainant under policy no.313205/48/2013/960 for the period from 27.10.12 to 26.10.13 for hospitalization period from 26.10.13 to 01.11.2013 the complainant got admitted on the last day of the policy on 26.10.2013 and the policy was renewed on 27.10.13.  Since the disease was pre-existing from 2008 the claim was settled by the OP Insurance Company for Rs.75,000/- i.e., previous sum insured and total sum insured was paid and no balance left.  The complainant again fell sick for the same type of disease as was earlier (heart ailment disease) and

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admitted to hospital for the second time on 14.11.2013 and after 14 days from the date of discharge of last hospitalization and lodged another claim which falls “anyone illness” clause as defined in the individual mediclaim policy clause no.3.17 and therefore claim under the said policy was repudiated by the OP by issuing letter dated 18.11.14.

Both parties relied on the medical paper and documents issued by the hospitals where the complainant was admitted and medically treated. 

Now we have to consider whether complainant was admitted on 26.10.2013 to 01.11.2013 and again 14.11.13 to 22.11.13 with same type of disease i.e., heart ailment disease.

On perusal of the discharge summary issued by Dr. Chhang’s Super Speciality Hospital, it appears that the complainant was initially admitted in North Bengal Neuro Centre on 24.10.2013 and treated on the line of Dengue Shock Syndrome and from North Bengal Neuro Centre he was referred to Dr. Chhang’s Super Speciality Hospital Pvt. Ltd., Matigara, Siliguri on 26.10.2013 and discharged on 01.11.2013.  Diagnosis at Discharge shows :- Coronary Artery Disease-ICMP, Type-2 Diabetes Mellitus, Dengue Sequelae with Malena and relevant investigation and treatment were made on the line of Dengue Shock Syndrome and in the discharge summary information given to patient and/or authorised representative was – (i) To be under medical supervision. (ii) To consult Physician for follow up regarding Dengue.  (iii) To consult Gastroenterologist for Malena.  So, it is clear that from 24.10.13 to 01.11.13 the complainant was admitted in North Bengal Neuro Clinic and thereafter in Dr. Chhang’s Super Speciality Hospital with Dengue Shock Syndrome. 

Again we find that complainant was admitted on 14.11.13 and 20.11.13 to 22.11.13 in Medica Super Speciality Hospital, Mukundapur, Kolkata, (Cardiology Department) for coronary angiography and coronary angioplasty of the complainant was performed there.  So, it cannot be held by any streatch of imagination that complainant admitted in Dr. Chhang’s Super Speciality Hospital on 26.10.13 with heart ailment disease and thereafter again admitted on 14.11.13 and 20.11.13 to 22.11.13 in Medica Super Speciality Hospital with the same type of disease i.e., heart ailment disease.  So, it is clear that both the disease of the complainant being different type of disease will not fall under “anyone illness” clause as defined in individual mediclaim policy clause 3.17.  It should be mentioned that in the policy No.313205/48/2013/907 dated 27.10.13 to 26.10.14 pre-existing disease i.e., heart ailment of the complainant was mentioned.

Again we find that complainant obtained mediclaim policy being no. 313205/48/2013/960 with effect from 27.10.12 to midnight of 26.10.13 and he

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took again the policy being no. 313205/48/2013/907 with effect from 27.10.13 to midnight of 26.10.14.  OP claimed that it was the renewal of the earlier policy, but we find in the mediclaim policy (individuals) in respect of renewal of policy it has been stated in clause 8(b) that the renewal of the policy is not automatic.  The premium due must be paid by the proposer to the company before the due date.  The policy no. 313205/48/2013/960 shows the period of insurance is from 27.10.12 to the midnight of 26.10.12 and the insurance policy was issued for a period of one year.  The due date of renewal of the said policy was before or within midnight of 26.10.12.  But the second policy was started from 27.10.13 which clearly shows that the policy holder/insured did not pay the premium before the due date or on the due date.  So, it is clear that the policy no. 313205/48/2013/907 is a separate policy and it is not the renewal of policy no. 313205/48/2013/960 as claimed by the OP.  Here we find that both the policies obtained by the complainant are separate policy and sun insured in each policy was Rs.1,25,000/-.  So, there is no hesitation to hold that the OP illegally and arbitrarily repudiated the claim of the complainant by letter dated 18.11.2014 showing that the complainant is not entitled to get mediclaim in view of clause 3.17 of the mediclaim policy and there is deficiency in service on the part of the OP/Insurance Company.  Accordingly, OP/Insurance Company is directed to pay the medical expenses to the tune of Rs.2,00,000/- i.e., Rs.1,25,000/- for the policy No. 313205/48/2013/907 and Rs.75,000/- only for the policy No. 313205/48/2013/960 and Rs.20,000/- towards damages for loss of energy, mental agony and harassment and Rs.5,000/- towards litigation cost.      

In the result, the case of the complainant succeeds in part. 

Hence, it is

                           O R D E R E D

that the Consumer Case No.65/S/2015 is allowed on contest in part against the OP with cost.

The complainant is entitled to get the medical expenses to the tune of Rs.2,00,000/- i.e., Rs.1,25,000/- for the policy No. 313205/48/2013/907 and Rs.75,000/- only for the policy No. 313205/48/2013/960 from the OP.

The complainant is further entitled to get Rs.20,000/- towards damages for loss of energy, mental agony and harassment from the OP.

The complainant is further entitled to get Rs.5,000/- towards the litigation cost from the OP. 

The OP/Insurance Company is directed to pay a sum of Rs.2,00,000/- i.e., Rs.1,25,000/- for the policy No. 313205/48/2013/907 and Rs.75,000/- only for the

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policy No. 313205/48/2013/960 towards medical expenses by issuing an account payee cheque in the name of the complainant within 45 days from the date of this order. 

The OP/Insurance Company is further directed to pay Rs.20,000/- by issuing an account payee cheque in the name of the complainant towards damages for loss of energy, mental agony and harassment within 45 days from the date of this order.

The OP/Insurance Company is further directed to pay Rs.5,000/- by issuing an account payee cheque in the name of the complainant towards the litigation cost within 45 days from the date of this order. 

 Failing which the amount will carry interest @ 9% per annum on the awarded sum of Rs.2,20,000/- from the date of this order till full realization. 

In case of default, the complainant is at liberty to execute this order through this Forum as per law. 

Let copies of this judgment be supplied to the parties free of cost.

 -Member-                                                          -President-