Complainant by filing this complaint has prayed for payment of Mediclaim amount of Rs.1,57,981/- against the op on the ground that complainant and his wife, son and daughter jointly purchased one Mediclaim Policy bearing No.101100/48/05/8500006455 on 05.01.2006 from the of  no.1 for a sum of Rs.1 lac, thereafter it was renewed year after year.  Thereafter lastly renewed for the period from 04.01.2008 to 04.01.2009 and he has holder of a valid insurance policy.

But subsequently on the way in rail during the travel from Agra to Kolkata on 15.08.2006 suddenly he became seriously ill and he was admitted in LPS Institute of Cardiology G.S.V.M. Medical College, Kanpur wherefrom he was released on 19.08.2006.

Thereafter on his return to Kolkata again he became seriously ill and was on examination of the said Divine Nursing Home and the said nursing home asked the complainant for better and proper care for cardiac treatment elsewhere and in persuasion of the advice of the Divine Nursing Home, complainant with the help of his friend was admitted to a Christian Medical College at Vellore on 05.09.2006 and remained under treatment as an Cardiac patient at his cost to the tune of Rs.1,57,921/- and it was paid fully by the complainant and was released.

          In dispose of cardiac trouble, complainant practically went to Vellore for treatment and after return the complainant submitted mediclaim along with all necessary papers regarding treatment and cost of treatment and lodged complaint.  But ultimately his claim was not cared by the ops.  Even he wrote letter to IRDA to assure him to look after the matter as contained in the letter of the complainant dated 19.09.2007 and ultimately did not settle the matter for which for negligent and deficient manner of service, complainant was compelled to file this complaint for redressal.

On the other hand the Insurance Company op no.2 by filing written statement submitted that the said policy was for sum assured of Rs.1,00,000/- and the policy was issued subject to certain terms and conditions of Mediclaim Policy so issued and in fact op received the claim application as filed by the complainant regarding payment of rs.1,57,921/- for his medical expenses.  But after considering the entire material and documents and the terms and conditions of the said policy, the complainant’s claim was rejected on the ground that pre-existing diseases as per Clause 4.1 & 4.3 of the Exclusion Policy.

          Further it is submitted as cost as per terms and conditions of the policy, complainant is not entitled to get it , so there was no question of giving him such benefit and for which there was no latches on the part of the op and in the circumstances, the claim was rejected and in the circumstances present complaint should be dismissed.

                               Decision with reasons

Practically in this case after considering the evidences on record of the both parties including the documents as filed by the complainant and the terms and conditions of the policy as produced by the op no.1 and hearing the Ld. Lawyers of both the parties, we have evaluated the terms and conditions of the policy of the complainant as which was valid for the period from 05.01.2008 to 04.01.2009 and fact remains the said mediclaim policy was valid for that period and Sudip Saha is covered by the said Mediclaim Policy for sum assured of Rs.1 lac-cum-bonus amount of Rs.10,000/- and in that policy it is specifically mentioned that the insurance shall no existence to pay any expenses incurred relating to diseases/sickness/injury mentioned in the Column of Section Appropriate there to or accelerated thereby or arising thereof and in this regard we have gone through the Clause 4.1 & 4.3 and as per Clause 4.1, it is found that the Exclusion Clause will also apply in any complication arising from pre-existing ailment/disease/injuries such complication will be considered as part of the pre-existing health condition of the diseases and if a person is suffering from Hypertension or Diabetic or at the time of taking admission, then policy shall be the subject to the following exclusion and further considering Clause 4.3 , it is found that certain treatment of diseases are excluded if those diseases are pre-existing at the time of proposal.  But if the diseases are pre-existing and the term of the proposal will be gathered only after 4 continuous claim policy years that means prior to the present policy if complainant is able to prove that he continuously continued proceeding 4 years policy without taking any benefit of the claim in that case complainant is entitled to get benefit of the pre-existing diseases treatment.

But considering the Annexure-E series, it is found that complainant consulted with the doctor on Medical College at Vellore on 29.08.2006 as out patient, 31.08.2006 as out patient and purchased some medicines from the main pharmacy of CMC.  Anyhow from discharge certificate as indoor patient form it is found that it was for the period from 16.08.2006 but discharge certificate it is not support that during the period of validity of the present Mediclaim Policy he was treated there as indoor patient.  Further prescription is found that on 24.08.2006 but the present claim is in respect of treatment started from 05.09.2006 and that claim was made by the complainant on 25.09.2006 and in support of that complainant filed the insurance policy may be for the period from 05.08.2006 to 04.01.2007.  But anyhow from the discharge summary it is found that his date of admission is 16.08.2006 to 19.08.2006.

But after that only he consulted with the doctor and along with discharge summary of Christian Medical College did not issue any treatment cost etc but pharmacy bills are produced and after accept medical bill no other bill for the treatment from 05.08.2006 to 29.08.2006 is produced.  But considering the pharmacy bills we find that there is no such prescription to that effect by the CMC that CMC charge any bill for medical treatment by the doctor of the CMC but pharmacy bills were paid of the pharmacy said CMC a separate unit to sell medicines to the patient and taking into the total amount as said pharmacy bill it is found that he paid Rs.405/- on 29.08.06, Rs.27,025/- on 29.08.06, Rs. 100/- on 31.08.06, Rs.670/- on 01.09.06, Rs.1,022/- on 02.09.2006, Rs.50/- on 03.09.2006, Rs.9,000/- also on that date and as in patient discharge bill finally issued by the CMC showing receipt of Rs.7,850/- only a period of terms is from 04.09.2006 to 05.09.2006.  But no other bill was submitted by the complainant.

Fact remains complainant has failed to prove that he spent Rs.1,57,921/- at any point of time.  Fact remains that he has not submitted discharge summary of the CMC.  But he has filed discharge summary of LPS Institute of Cardiac developed for the period from 16.08.2006 to 19.08.2006 and one prescription of Divine Nursing Home dated 24.08.2006 .  But anyhow discharge summary of CMC is not filed.  But it is proved that he consulted with the doctors of CMC day to day on different dates and purchased medicines and as in patient, patient discharge bill for the period 02.09.2006 to 05.09.2006 was submitted showing bills of Rs.7,850/- only which has been already ventilated in the previous para of judgement.

Considering all the above facts and materials we have found that complainant has practically prayed for mediclaim of Rs.1,57,921/- but in support of such claim no such document is produced by the complainant.  But on proper scrutiny of the present document as produced by the complainant it is found that complainant for his treatment at CMC Vellore spent only Rs.15,000/- to Rs.20,000/- for medicine and it is evident from the receipt as produced. But unfortunately complainant has not produced the discharge summary of the CMC at Vellore for certain reasons because if it would be produced in that case it would ventilated that he has been suffering from pre-existing disease for which he suppressed the same he did not submit the same and fact remains op no doubt refund the claim on the ground that there was pre-existing disease.  But we are of no consult in that fact.  At this stage in view of the fact, complainant has been able to prove that he spent Rs.20,000/- around as in patient of CMC at Vellore which is evidence from the discharge bill.  So, that amount may be granted in favour of the complainant.  Complainant is not willing to get dischargeable amount as mediclaim policy.  But he has been claiming Rs.1,57,921/- but in support of that complainant has failed to produce any paper before this Forum for which under any circumstances, it is not possible to grant the said amount when complainant has not produced all those bills in support of his claim and accordingly we are giving the said amount of Rs. 20,000/- including some co-related cost of Rs.5,000/- i.e. total of Rs.25,000/- to the complainant after considering his treatment.  Only treatment on the ground complainant has not produced the document, the discharge certificate of the CMC at Vellore in this case.         

          In the result the present complaint is disposed of.

Hence, it is

                                              ORDERED

That the complaint be and the same is allowed in part against the ops and particularly against op nos. 1 to 6 on contest with cost of Rs.2,000/-.

Op nos. 1 to 6 are hereby directed to handover the sum of Rs.25,000/- as final settlement of the mediclaim of the complainant within one month from the date of this order failing which op nos. 1 to 6 shall have to pay punitive damages @ Rs.300/- per day till full satisfaction of the decree and if it is collected the same shall be deposited to the State Consumer Welfare Fund.

          Op nos. 1 to 6 are hereby directed to comply the order very strictly failing which for disobeyance of the Forum’s order penal measure shall be taken against them and further penalty may be imposed as per law.