West Bengal

Dakshin Dinajpur

CC/19/2022

Mr. Partha Pratim Kundu, S/O- Dhirendra Nath Kundu - Complainant(s)

Versus

The Managing Director, Reliance General Insurance Company Limited - Opp.Party(s)

Mintu Das

08 Aug 2023

ORDER

The instant case has been initiated under section 35 of the Consumer Protection Act, 2019 claiming an amount of Rs.29,300,/- + Rs.14,000/- + Rs.26,000/- + Rs. 10,000/- towards compensation + towards litigation cost of Rs.10,000/- (Total amount = Rs. 89,300/-)

 The fact of the case, in brief, is that the complainant purchased a Hospitalization & Domiciliary hospitalization Insurance Policy of Rs. 3,00,000/- each for his family, i.e. for himself his spouse, and his two daughters from the National Insurance Company Limited in the year 2005 and he renewed the said policy year after year and lastly in the year 2019 he ported his said policy to the Reliance General Insurance Company Limited and he properly renewed the said policy from the Opposite Party / Insurance Company since then and lastly on 31.03.2021 by paying the yearly premium of Rs. 22,202/- for this year and Opposite Party issued Policy Cover Note vide Policy No. 718222128240000079. Thus, the complainant became a consumer of Opposite Party within the meaning of Consumer Protection Act.

The wife of the complainant, namely Susmita Kundu was treated for the problem of her eye, firstly at Netralayam Eye Hospital, 330 Barakhola, Mukundapur, Main Road, E.M. Bypass, Kolkata- 7000099 and thereafter at L.V. Prasad Eye Institute, Kallam Ansi Reddy campus, L.V. Prasad Marg, Hyderabad, Telangana. Netralayam Eye Hospital charged for two injection and other costs Rs. 29,300/- on 01.09.2021& Rs. 26,000/- on 24.09.2021 and L.V. Prasad Eye Institute charged Rs. 14,000/- on 02.12.2021 and the petitioner paid total bill of Rs. 51,605/- for the said treatment of his wife and he claimed the said bill from the Opposite Party/ Insurance Company as per the terms of the policy of Company. But the Opposite Party/ Insurance Company  rejected the claim of the petitioner by saying that the patient got admitted for non-proliferative diabetic retinopathy and as per documents provided patient has known history of diabetes mellitus since 16 years. Whereas the treating Doctor never opined in his patient case summery that the patient has a past history of other illness, or that the reason of Macular Edema is caused for diabetes of the patient. It is a clear case of deficiency of service and the O.P. willingly and without any reasonable ground rejected the claim of the petitioner and they cannot deny the just claim of the petitioner. Finally, the petitioner became bound to take the shelter of this Honorable Forum for getting proper redress.

          Notice was issued upon the Opposite Party and after receiving the notice the opposite party appeared before this Commission and filed his written version.

             By filing written version, the Opposite Party has stated that it is true that the complainant Partha Pratim Kundu was a policy holder of us and the said policy was valid and her wife Sushmita Kundu was also covered for her medical claim. There was no deficiency in the service on the part of the O.P. Reliance General Ins. Co. Ltd. to the complainant. It is true that complainant’s wife admitted at Shankar Netralay and she had taken Retina injection in her left eye for Macular Edema. And so complainant claimed Rs. 29,809/-. The inception date of insurance policy No. 718222128240000079 was 31.03.2021. That during inception of policy, the complainant never disclosed that her wife had past history of diabetes, but at the time of claim of Rs. 29,809/-, the complainant admitted in his written statement that her wife had previous history of diabetes. Due to non-disclosure of previous history of illness/ diabetes, after completion of claim processing, the claim of complainant was rejected vide letter dated 15.09.2021. Hence, the said insurance company inform the complainant that claims stands denied and policy also stands cancelled as per Reliance Health infinity policy as per policy clause i.e. Non-Disclosure or Misrepresentation of fact.

Exclusions-

Non-Disclosure or Misrepresentation -  Any material facts in the information provided to us in the proposal from or by insured member, if found to be incorrect, incomplete suppressed or not disclosed willfully or otherwise the policy shall be cancelled ab initio from the inception date or renewal date or the policy may be modifies by us or at sole discretion upon 30 days notice by sending an endorsement to your address shown in schedule without refund of premium & any claim made under such policy shall be rejected/ repudiated forthwith. The complainant never informed this O.P. or claimed Rs. 26,000/- for the other cost of her wife’s treatment dated 24.09.2021 and Rs. 14,000/- for charges of L.V. Prasad Eye Institute, dated-nil. As such the claim petition is not maintainable and bad in the eye of law and is liable to be dismissed.

       In support of his case, the complainant has filed the photo copies of the following document-

1. Insurance Policy No. 718222-1282-40000079
2. Rejection Letter of O.P.
3. Health Claim Form
4. Details of expenses of Netralayam Eye Hospital and L.V. Prasad Eye Institute

               On the other hand the Opposite Party has failed to submit any document in support of in his defense.

                    In view of the above mentioned discussions the following points cropped up for determination.

 

                   Points for determination

1. Is the complainant a consumer to the Opposite Parties?
2. Is there any negligence and deficiency in service on the part of the Opposite Parties?
3. Is the Complainant entitled to get any relief/reliefs as prayed for?

 

 

 

                                                                      REASONED DICISION

                 We have heard argument by Ld. Advocates for the both sides at length.  Perused the materials on record, evidence on affidavit and written argument filed by the parties. We have also gone through the documents produced before us.

             At the time of argument, Ld. Advocate for the Complainant narrated the fact of the case as mentioned in the complaint petition. Ld. Advocate further submitted that on the false ground, the claim of the Complainant has been repudiated by the Opposite Party. There is negligence and deficiency in service on the part of the Opposite Party. The Complainant has proved his case so, he is entitled to get relief as prayed for.

          On the other hand, Ld. Advocate for the Opposite Party also narrated his defense case as mentioned in the written version. Ld. Advocate for the Opposite Party further submitted that due to non-disclosure of the previous history of illness / diabetes and for that reason the claim of the Complainant has been repudiated. There is no latches  or deficiency in service on the part of the Opposite Party. So, the instant case is liable to be dismissed.

 

Let all these points be discussed one by one -

 

Point  NO. 1  

 

              It is admitted by the Opposite Party in his written version that the Complainant was a policy holder and the said policy was valid and her wife Sushmita Kundu was also covered for her medical claim. Hence, this Commission is of the view that the complainant is a consumer u/s 2(7) of Consumer Protection Act 2019.  

          Accordingly, this point is decided in favour of the Complainant.               

 

Points No. 2 & 3  

           Both these points are taken up together for the sake of convenience and brevity.

         It is an admitted fact that the Complainant purchased a Hospitalization & Domiciliary hospitalization Insurance policy of Rs.3,00,000/- from the Opposite Party for himself, his spouse and for his two daughter in the year 2019. Firstly, he purchased the said policy from the National Insurance Company Limited in the year 2005 and he renewed the said policy year after year and in the year 2019 the Complainant ported the said policy to the Opposite Party and lastly on 31.03.2021 he paid yearly premium of Rs.22,202/- to the Opposite Party for the said policy.  

               It is also an admitted fact that the wife of the Complainant namely Susmita Kundu was treated for the problem of her eye, firstly at Netralayam Eye Hospital at Kolkata and thereafter at L.V.Prasad Eye Institute, Hydrabad, Telangana.

            Further, The Netralayam Eye Hospital charged for two injection and other costs of Rs.29,300/- on 01.09.2021 & Rs.26,000/- on 24.09.2021 and L.V.Prasad Eye Institute charged Rs.14,999/- on 02.12.2021. Thus, the Complainant spent total bill of Rs.51,605/- for the treatment of his wife.

          Here, it is contention of the Complainant that when he submitted claim of the said amount for refund, the Opposite Party rejected the claim on the ground that the patient has known history of Diabetes Mellitus since 16 years and the same has not been disclosed by the Complainant at the time of parting of the insurance policy.

          Now, on perusal of the Insurance Policy it appears that the Complainant and his wife including two twin daughters are insured for Rs.3,00,000/- with Reliance Health Infinity-Policy Scheme of the Opposite Party for the period from 31.03.2021 to 30.03.2022. It has not been challenged by the Opposite Party that the wife of the Complainant was not administered injection for treatment of her eye on 01.09.2021, 24.09.2021 and 02.12.2021. Further, on perusal of the claim forms it appears that two claim of Rs. 29,300/- and Rs.26,000/- have been submitted before the Opposite Party. There is a bill of L.V.Prasad Eye Institute of Rs.14,000/- but claim form of the said amount has not been produced before this Commission by the Complainant. In other words, it can be said that the Complainant has not claimed Rs.14,000/- before the Opposite Party. 

           Again, on perusal of the Rejection letter / Repudiation letter of the Opposite Party, it appears that the claim no.201210055728, claimed amount Rs.29,809/- has been rejected as per documents provided in AL – 101210024855 patient has known history of Diabetes Mellitus since 16 years and the same is not disclosed at the time of policy inception with the Opposite Party. Here, the Opposite Party has failed to produce the document AL – 101210024855 before this Commission to show that the wife of the Complainant has Diabetes Mellitus since last 16 years and that has not been disclosed at the time of inception of the policy before the Opposite Party. So, the allegation of the Opposite Party is not believable and considerable. Apart from it, in the Discharge Summary of L.V.Prasad Eye Institute, there is no mentioning that the patient has Diabetes Mellitus since a long time.

      Now, as per observation held by the Hon’ble West Bengal State Consumer Disputes Redressal Commission, in S.C. Case No. – F.A./587/10 between Shri Sunil Kumar Dutta Vs United India Insurance Co. Ltd. & others that even if it is taken for granted that such pre-existing disease necessitated  implantation of pace maker, then also he has lived like a normal human being for 20 years, at par with the normal human being having no pre-existing disease. So, Insurance cover had not been taken with the malafide motive of chance exploitation. Similarly, in the instant case, the Opposite Party can not escape himself from refunding the claim of the Complainant.

            Further, the claim of Rs.26,000/- is neither repudiated nor settled by the Opposite Party. So, there is still a scope for repudiation or settlement by the Opposite Party.

. In view of the above mentioned findings, this commission is of opinion that the Complainant is a consumer to the Opposite Party and there is negligence and deficiency in service on the part of the Opposite Party so, the Complainant is entitled to get  any relief .

.        Accordingly, both these points are decided in favour of the Complainant.

     

 

 

  Hence, it is

                                                 O R D E R E D

 

            That the complaint case No. 19 of 2022 be and the same is allowed on contest in part against the Opposite Party but with cost. 

            The Opposite Party is directed to pay a sum of Rs.29,300/-/- together with an interest @ 8% p.a. from 03.09.2021( the date of filing claim) till full realization by issuing an account payee cheque in favour of the Complainant within 45 days from the date of passing of this order failing which the Complainant is at liberty to excute the order as per law. The Opposite Party is further directed to pay Rs. 5,000/- towards compensation and Rs.5.000/-towards litigation cost within the above mentioned period.

         The Opposite Party is further directed to repudiate or settle  the claim of Rs. 26,000/- as expeditiously as possible. The Opposite Party is also directed to settle the claim of Rs.14,000/- if claimed by the Complainant. Expeditiously.

Let a plain copy of this order be supplied to the parties free of cost