For the Complainant:Self
For theOP No.1:Exparte
For the OP No.2 & 3: Sri B.K.Panda, Advocate, Bhawanipatna.
JUDGEMENT
The facts of the complaint in brief is that the complainant has availed an Mediclaim Insurance Policy from Opp.Party vide Policy No.005628590 and MD11536085,MDI ID No.MD15-0012840116 . The complainant had undergone for medical treatment to Cuttack during the month of June, 2012 and further went to Appollo Hospital, Bhubaneswar from 15.09.2012 to 18.09.2012 and from 24.09.2012 to 11.10.2012 and at CMC, Vellore from 29.10.2012 to 12.11.2012 for her treatment. As per the Opposite Party No.1 letter dt.5.11.2013 and 24.12.2013 the complainant submitter all the papers to the Opposite Party on dt.16.12.2013 for sanction of medical claim. But till date the Opposite Party has not responded to the claim of the complainant. Finding no other option the complainant has filed this complaint and prayed to direct the Ops to pay the mediclaim amount along with compensation for mental agony . Hence, this complaint.
Being noticed the Opp.Party No.1 did not prefer to file to any written version as such the Opp.Party No.1 was set exparte and the Opp.Party No.2 appeared through Sri B.K.Panda, Advocate and filed written version denying the petition allegations on all its material particulars.
It is submitted by the OP No.2 that the Life Assured complainant procured a policy bearing No.005628590 on 21.06.2012 and thereafter a claim was received by the Opposite Party on 13.02.2013 with regard to hospitalization of the complainant from 24.09.2012 to 11.10.2012.After reviewing the documents filed by the complainant, it was found that the life assured was having the disease of Dermatomyositis and had consulted the doctor Balkrishna Kuanar and Dr.Mamata Sahu on 04.06.2012 and 5.06.2012 i.e. prior to submission of the proposal form and has concealed and misrepresented material facts pertaining to her health condition and medical ailment. Owing to the above mentioned reasons, the Opposite Party repudiated the policy claim under Section 45 of the Insurance Act,1938. The complainant has also submitted the letter where the complainant herself accepted the fact that due to muscle problem, the complainant has consulted the doctors during the month of June to July,2012 and as per their advised she took medicines. In view of the above facts and evidence, the contract stands void ab initio and the claim of the complainant under the said policy was repudiated and the same was communicated to the complainant. There is no deficiency has been caused to the complainant by the Opposite Party and hence prayed to dismiss the complaint.
FINDINGS
Heard argument from both the parties. The complainant submitted that the petitioner had no disease as alleged by the Opposite Party No.2 in their written version and therefore, the insurance claim made by the complainant was fully justified and the terms and conditions of the mediclaim insurance policy raised by the Opposite Party cannot be invoked in the present case and the Insurance Company ought to have reimbursed the expenses incurred by the complainant in her treatment and hospitalization.
On the other hand Sri B.K.Panda, Advocate for the Insurance Company submitted that the complainant was having the disease of Dermatomyositis and had consulted the doctor prior to submission of the proposal form and has concealed and misrepresented material facts and as such the Opposite Party repudiated the policy claim under Section 45 of the Insurance Act,1938 and the complainant herself accepted the fact that due to muscle problem, the she has consulted the doctors during the month of June to July,2012 and as per their advised she took medicines.
It is admitted fact that the complainant has been availing mediclaim insurance policy from the Opposite Party since 2012 and it is also admitted by both the parties that the third year mediclaim policy has been issued in favour of the complainant. It is further admitted by the Insurance Company that the complainant claimed for her medical expenses when the policy was in force. But the Opposite Party repudiated the claim on the ground that prior to submission of the proposal form the complainant has concealed and misrepresented material facts pertaining to her health condition and medical ailment as per Section 45 of the Insurance Act,1938. On the other hand the complainant to substantiate her case has filed one Medical Certificate dt.08.05.2017 issued by the Pradyumna Bal Memorial Hospitl, Kalainga Institute of Medical Sciences(KIMS) wherein Dr.Prasanta Padhan,Regd. No.13883/OR/2000 has certified that the complainant Miss. Soudamini Majhi, aged 58 years is suffering from Dermatomyositis and her illness started in the month of September,2012. On perusal of the above certificate it is clear that the Opposite Party issued the Mediclaim Policy on 21.06.2012 and the illness started in the month of September,2012 and the claim of the complainant is genuine and within the coverage period of the policy.
We perused the case law in the instant case where it is held and reported in CPC- 1991, page -540 where in the Hon’ble Haryana State Commission held that when ever there is any delay or dilatoriness in finalizing the insurance claim, the same would be tantamount to a deficiency in service and thus comes squarely within the purview of Consumer Forum. Once it is held that default or negligence in the settlement of an insurance claim is a deficiency in service then an arbitrary or mischievous rejection of an insurance claim would patently be a default within its larger meaning. The mere repudiation of the insurance claim cannot itself operate as a jurisdiction bar for redressal forums under the Act. it is held and reported in CPR-1991(2), page No.18 where in the Hon’ble National Commission clearly defines the mere unilateral rejection of medi claim as claimed by the complainant does not per se operate as jurisdictional bar to seek redressal before the forums under the Act. It is on the strength of the above decision the instant case is admitted by this forum.
In the case of Biman Krishna Bose Versus United Insurance Co. Ltd. and Anr., the Apex Court has held that :
Where an Insurance Company under the provisions of the Act having assumed monopoly in the business of general insurance in the country and thus acquired the trappings of the State being other authorities under Article 12 of the Constitution, it required to satisfy the requirement of reasonableness and fairness while dealing with the customers. Even, in an area of contractual relations, the State and its instrumentalities are enjoined with the obligations to act with fairness and in doing so, can take into consideration only the relevant materials. They must not take any irrelevant and extraneous consideration while arriving to a decision. Arbitrariness should not appear in their actions or decisions.
The Opposite Party No.2 in written version contended that the complainant concealed the many material facts concerning to this case. In the present case the O.Ps have entered into an insurance contract with the complainant and by repudiation of such claim they have defeated the very purpose of the insurance. The Opposite Party has mentioned in their written version that they have issued the policy with utmost good faith . Generally the Insurance Company before issuing any insurance policy they are taking the medical test of the concerned person before issuing any policy and how can they say that they issued the policy in good which are not admissible in the eye of law. Hence the complainant is deemed to have not suppressed any material facts and after due consideration the Opposite Party has issued the policy accepting the conditions.
In the above facts, circumstances & on perusal of the record, the complaint petition, documents, and referring on above Citations there exists a strong “prima-facie” case in favor of the complainant.
On the strength of the aforesaid rulings of the Apex court this forum allow this case in part. Hence to meet the ends of justice, the following order is passed. ORDER
In the result with these observations, findings & discussion the complaint petition is allowed in part as per her prayer on contest. Hence, the Opposite Party No. 2 is directed to settle the Mediclaim Insurance and pay the insured amount to the complainant within 45 days from the date of receipt of this order and failing to pay the same within the stipulated period of 45 days , the OP No2 is liable to pay 9% interest on the above awarded amount till the date of its payment.
Pronounced in open forum today on this 11th day of January,2019 under the seal and signature of this forum.
Member President
Documents relied upon:
By the complainant:
- Copy of Policy document
- Copy of discharge bill.
- Copy of In Patient Bill No.ORB1-ICS-15783 dt.18th Sept,
- Copy of In Patient Bill No. ORB1-ICS-16335 11.10.2012
- Copy of Certificate dt.08.05.2017.
- Copy of Reimbursement claim application
- Copy of Letter dt.19.03.2016 of OP No.2
- Copy of letter of the Complainant dt.28.03.2016 to OP No.2
- Copy of letter of OP No.2 dt.01.04.2016,11.04.16
- Copy of letter dt.22.08.2016 of the Complainant to OP No.3
- Copy of letter of OP No.3 regarding Repudiation of the Claim dt.12.09.2016
- Copy of Pass Book of OBC Bank of the Complainant
By the OP No.3:
- Copy of Prospectus of Oriental Bank Mediclaim Policy
- Copy of Discharge Summary of Complainant
President
