Date of filing: 05.08.2015 Date of disposal: 17.02.2017
Complainant: Manas Tewari, S/o. Lt. Lakshmi Narayan Tewari, resident of Borehat, Water Tank, P.O.-Natunganj, Dist.-Burdwan, Pin-713102.
-VERSUS-
Opposite Party: 1. The National Insurance Co. Ltd., represented through its Divisional
Manager, having its office at 548, G.T. Road, Bhangakuthi, Burdwan,
Pin-713101.
2. T he Medi Assist India Pvt. Ltd., represented through its Manager, having
its office at # 4, ‘Premier Court’, 4th floor, Chandni Chowk Street, Kolkata,
Pin-700 072.
3. The Superintendent, Amri Hospital, Salt Lake (A unit of Amri Hospital Ltd.),
having its office at JC-16 & 17, Salt Lake City, Sector-III, Kolkata, Pin-700 098.
Present : Hon’ble Member : Smt. Silpi Majumder
Hon’ble Member : Sri Pankaj Kr. Sinha
Appeared for the Complainant: Ld. Advocate, Suvro Chakraborty.
Appeared for the Opposite Party No.1: Ld. Advocate, Shyamal Kumar Ganguli.
Appeared for the Opposite Party No.2: None.
Appeared for the Opposite Party No.3: Ld. Advocate Subrata Ghosh.
J U D G E M E N T
This complaint is filed by the Complainant u/S. 12 of the Consumer Protection Act, 1986 alleging deficiency in service, as well as, unfair trade practice against the OP as the OP has repudiated his legitimate insurance claim arbitrarily and whimsically.
The brief fact of the case of the Complainant is that he obtained a Group Medi-claim Insurance Policy from the OP for the year 2001 for treatment and hospitalisation expenditure. The risk of the policy was covered up to Rs.1, 00,000=00 The Complainant used to renew the policy from year to year upon making payment of due premium amount. The policy was valid for the period from 31.03.2013 to 30.03.2014 by covering the risk of himself, his wife, son and his daughter Shreya Tewari. Next year the policy was renewed accordingly and the same was valid for the period from 31.03.2014 to 30.03.2015 and the liability of the Insurance Company for the year was for Rs.1, 50,000=00. During continuation of the policy as per advice of Dr. Subroto Chakraborty the daughter of the Complainant was admitted at AMRI Hospital, Salt Lake, Kolkata i.e. the OP-3 on 13.06.2013 as she was suffering from relapsing Hepatitis and she had to undergone treatment there up to 18.06.2013. At the time of admission the OP-3 received the Xerox copy of the medi-claim policy from the Complainant, but the OP-3 did not intimate anything regarding expenditure as she got admission in cashless. Since the date of admission the OP-3 did not say anything regarding payment of bill to him. Moreover when the patient party wanted to know the matter along with the insurance benefit the OP-3 assured the Complainant that the total cost of the treatment of his daughter will be borne by the Insurance Company. He was further told by the OP-3 that in case of any complication then the OP-2 will make contact with the OP-2 and the Complainant. But very surprisingly in the evening of 17.06.2013 when the treating doctor opined that the daughter of the Complainant is well and also opined for discharging the patient, then the OP-3 made a bill of Rs.17,785=00as treatment expenses and asked the Complainant for making payment of the same. Having heard the same the Complainant became surprised and asked the OP-3 about cashless treatment benefit, then the men of the OP-3 threatened the Complainant and begun to create pressure upon the Complainant for making payment of the said bill. Moreover from the evening of 17.06.2013 till evening of 18.06.2013 the OP-3 instead of taking care of the patient started to mis-behave with the Complainant and treat the patient inhumanly. The Complainant requested the OP-3 then the OP-3 directed him to pay the bill at first, otherwise police will be intimated. On 18.06.2013 the Complainant for the first was intimated by the OP-3 that the treatment of his daughter has not come under cashless facility. Being aggrieved the Complainant lodged GED with the Biddhannagar Police Station being no-1350/2013 dated 18.06.2013. Thereafter the Complainant contacted with the finance officer of the Burdwan University who advised him to pay the amount and assured that the Insurance Company will reimburse the amount to him. As such the Complainant paid the amount to the OP-3. After discharging his daughter the Complainant requested the OP-1 through the OP-2 for reimbursement of his claim. The OP-2 send a letter dated 22.07.2013 to the Complainant asking for providing some documents and the Complainant accordingly provided the same to the OP-2. But the OP-1 and 2 remained silent over the matter and then the Complainant made written correspondences and the OP-1 issued a letter to him dated 18.08.2014 stating the claim of the Complainant as ‘no claim’. The Complainant send a letter to the OP-1 on 09.10.2014 requesting to consider his claim but the OP had repudiated the claim of the Complainant by issuing letter dated 14.10.2014. According to the Complainant as the Insurance Company did not reimburse his legitimate insurance claim, hence finding no other alternative the Complainant has approached before this Ld. Forum by filing this complaint praying for direction upon the Insurance Company to pay a sum of Rs.22, 280=00 towards the medical expenditure incurred by him for treatment of the insured daughter, Rs.25, 000=00 as compensation due to mental agony, harassment and pain and litigation cost of Rs.25, 000=00 to him. The Complainant has also prayed for an interest @12% p.a. on the amount from 14.10.2014 till realisation.
The petition of complaint has been contested by the OP-3 by filing written version contending that this OP is a well equipped and renowned registered hospital having RMO & trained nurses. From the documents it would be evident that this OP has provided facilities to the patient in accordance with the procedure prescribed by the medical science and did not commit any negligence towards the treatment of the patient. There is no iota of evidence that the service provided to the patient suffers from any deficiency in service, but the Complainant has made this OP unnecessarily. Within the four corners of the complaint no allegation has been made out by the Complainant regarding medical negligence against this OP, so the Complainant is not entitled to get any relief as sought for. This OP has further submitted that one patient-the daughter of the Complainant was admitted at the OP-2 on 13.06.2013 and got discharge from this OP on 18.06.2013. At the time of admission the patient was admitted under Medi Assist-TPA of the Insurance Company and after admission this OP applied before the TPA for cashless authorization of the patient, but during her hospitalisation the cashless authorisation was denied by the TPA. Therefore the patient was transferred from TPA to general cash patient and subsequently the patient party paid total hospital bill amount in cash at the time of discharge. As there is no allegation in respect of medical negligence against this OP, the OP-3 has prayed for dismissal of the complaint with cost.
The petition of complaint has been contested OP-1 by filing written version contending that admittedly the daughter of the Complainant came under the insurance (medi-claim) coverage with this OP in the year 2011. During taking out the medi-claim policy by the daughter of the Complainant in the proposal form nowhere it is mentioned under the column of statement of her health that she suffered from hepatitis in the year 2010, June. As the daughter of the Complainant did not disclose the actual state of her health in the proposal form, hence there is suppression of material fact in providing the statement of fact in the proposal form. Similar episode occurred in the year 2012, October with de-arranged liver function. In respect of the present complaint and claim lodged by the Complainant regarding reimbursement of the medical expenditure as incurred by him for the treatment of her insured daughter at the OP-3, the claim of the Complainant was processed by the Insurance Company, some documents was sought for by the Company but from the discharge certificate as it is evident that though the daughter of the Complainant suffered from the similar sufferings before inception of the policy but the same was not disclose by her in the proposal form. In view of the terms and the conditions of the policy the claim of the Complainant has been repudiated correctly. The information of repudiation of the claim was duly been intimated to the Complainant by issuing repudiation letter mentioning that on the ground of pre-existing disease the claim lodged by the Complainant is closed as ‘No claim’. According to the OP-1 there is no deficiency in service on its behalf because it had processed the claim within the stipulated period and repudiation of the claim had duly been intimated to the Complainant by issuing repudiation letter. According to the OP-1 repudiation of any claim cannot be termed as deficiency in service as well as unfair trade practice. As there was not inordinate delay in deciding the claim lodged by the Complainant hence, the action of the OP-1 does not suffer from any deficiency in service. As there is no merit in the complaint, prayer is made by this OP for dismissal of the complaint.
The Complainant has adduced evidence on affidavit along with several papers and documents in support of his contention.
We have carefully perused the entire record; documents, policy copy, terms and the conditions of the said policy, treatment related papers of the patient concerned, written correspondences made by and between the Complainant and the Insurance Company, repudiation letter issued by the Insurance Company and heard argument at length advanced by the Ld. Counsel for the contesting parties.
It is seen by us that admittedly the Complainant obtained a Group Medi-claim Insurance Policy from the National Insurance Company in the year 2000 covering the treatment and hospitalization etc. At that point of time the risk of the policy was covered up to Rs.100, 000=00. The Complainant used to renew the said policy year after year subject to making payment of the due premium amount. Subsequently his daughter was included in the said policy in the year 2011. During validity of the said policy his daughter became ill and as per advice of the doctor the daughter of the Complainant got admission at AMRI Hospital, Salt Lake, Kolkata on 13.06.2013 as she was suffering from ‘Relapsing Hepatitis’. The daughter of the Complainant had to undergone treatment at the OP-3 till 18.06.2013. From 13.06.2013 to 18.06.2013 the Complainant had incurred medical expenditure for the treatment of his daughter to the tune of Rs.22, 280=00. After getting release from the hospital the Complainant lodged the insurance claim before the Insurance Company along with the relevant documents and papers. The Insurance Company sought for some documents from the Complainant by issuing letter and the Complainant complied with the same accordingly. But ultimately the claim of the Complainant was repudiated by the Insurance Company on the ground of pre-existing disease, which was not disclosed by the insured in the proposal form at the time of taking out the said policy in the year 2011. Upon receipt of the repudiation letter the Complainant made written correspondence with the Company requesting to re-consider his claim, but to no effect and his claim file was closed by the Company as ‘No claim’. The allegation of the Complainant is that the Insurance Company has repudiated his legitimate insurance claim arbitrarily and whimsically. Further allegation of the Complainant is that at the time of discharge of the patient the OP-3 behaved with him in an inhuman manner. In support of such plea it is stated by the Complainant that though he was told by the authority of the OP-3 that the treatment of his daughter will be cashless under the Insurance Policy but subsequently at the time of discharge the OP-3 claimed a sum of Rs.22,280=00 from him towards hospital bill. According to the Complainant as he was not prior intimated by the OP-3 that payment will be made by him out of his own pocket, subsequently when he came to know that the treatment expenditure will not be cashless, rather he is to pay the entire hospital bill amount, then he became so surprised with such behaviour and action of the OP-3. The Complainant has alleged that the action and service of the OPs suffer from deficiency in service.
We are to adjudicate first as to whether there was any deficiency in service on behalf of the OP-3 or not. Though the Complainant has taken the abovementioned plea against the OP-3 alleging its deficiency in service, but no documentary evidence is produced before us from where it is evident that actually the OP-3 had misguided this Complainant stating that the treatment of his daughter will be cashless. As the Complainant has failed to corroborate his allegation by adducing cogent evidence, hence such wild allegation does not stand at all.
Next, we are to see as to whether there was any deficiency in service on behalf of the Insurance company or not. In this respect we are to say that the claim lodged by the Complainant was duly processed by the Company, some documents sought for and it was found by the Company that as the insured did not disclose her actual state of health in the proposal form at the time of taking out the policy in the year 2011, hence the claim is not payable because the complainant’s daughter got admission at the OP-3 on 13.06.2013 due to her suffering from pre-existing disease. It is further submitted by the Insurance Company that the complainant’s daughter suffered from the similar ailment in the year 2010, June and 2012, October with de-arranged liver function, but prior to taking out the policy as the daughter of the Complainant was treated for the same illness in the year 2010, but the same was not disclosed in the proposal form and based on this point only the Insurance Company had repudiated the claim of the Complainant. We have noticed that the earlier sufferings of the insured were very much within her knowledge along with her father, but as the same was not disclosed in the proposal form hence, such suppression of the material fact in the proposal form was done by the complainant and her daughter fraudulently. There are several judgments passed by the Hon’ Supreme Court (case of Mithoolal Nayek and the case of Asha Goel) wherein Their Lordships have observed that where there is fraudulent suppression of material fact in the proposal form at the time of taking out the policy by the intending insured, the repudiation of the claim by the insurer cannot be termed as deficiency in service and illegal. We have noticed from the discharge summary as issued by AMRI Hospital, Salt lake, Kolkata dated 18.06.2013 wherein it is written that similar two episodes of jaundice occurred in June, 2010 and October, 2012 with de-arranged liver function and under the column ‘diagnosis’ it is written ‘Relapsing Hepatitis’. Hence, it is clear to us that in this occasion i.e. on 13.06.2013 Hepatitis relapsed. Based on this document only the Insurance Company had repudiated the claim of the Complainant. In our view as the Insurance Company based on the specific terms and conditions of the policy repudiated the claim of the Complainant, in our view the same cannot be termed as deficiency in service on its part, rather deficiency occurred on the part of the Complainant as he/his daughter suppressed the actual state of the health of her daughter in the proposal form and the same was done in a fraudulent manner. Therefore the repudiation cannot be termed as deficient service as alleged by the complainant. As the complainant has failed to prove his case hence he is not at all entitled to get any relief as prayed for. Therefore the complaint fails.
Going by the foregoing discussion hence, it is
O r d e r e d
that the complaint is dismissed on contest. However, considering the facts and circumstances of the complaint there is no order as to cost.
Let copies of this order be supplied to the parties free of cost as per provisions of law.
(Dictated and corrected by me.
(Silpi Majumder)
Member
DCDRF, Burdwan
(Pankaj Kumar Sinha) (Silpi Majumder)
Member Member
DCDRF, Burdwan DCDRF, Burdwan
