Date of filing : 25.05.2017.
Decided on : 19.12.2019.
JUDGEMENT
Bibekananda Pramanik, President – This consumer complaint under section 12 of C.P. Act, 1986 has been filed by the complainant Smt. Srabani Basu against the O.P. – The Oriental Insurance Company Limited alleging deficiency in service on the part of the O.P.
Complainant’s case, in brief, is as follows :-
The complainant entered into a Happy Family Floater Policy vide Policy No. 311400/48/2014/3083 with the O.P. – Insurance Company on 08.08.2013 and the said policy was renewed till 08.08.2017. In the said policy, the complainant was the proposer of Sumit Kumar Bose, the husband of the complainant, her son Satyaki Basu and her mother Pranati Ghosh. On 06.08.2015, said Pranati Ghosh was admitted by the complainant in the emergency of Desun Hospital and Heart Institute at E.M. Bypass, Kolkata – 700 107 due to sudden chest pain, vomiting and sweating. In the emergency - O.P.D. prescription dated 06.08.2015 it was written that the patient was having chest pain, vomiting and sweating and in the said prescription in HTN column it is cross marked as there was no sign of any hypertension. After treatment in the said hospital, the mother of the complainant was discharged on 10.08.2015. After such discharge, the complainant submitted all medical reports, prescription, test reports, purchase receipt of medicine, discharge summary along with Mediclaim Form in the office of the O.P. on 14.09.2015 with a claim for reimbursement of an amount of Rs. 1,08,025/- for such treatment of her mother. Subsequently the complainant came to know that her claim was denied by the O.P. as per clause no. 4.3 (XVII) with the reason that during the period of insurance, the expenses of treatment of hypertension within a period of 2 (two) years from the date of policy the complainant cannot claim reimbursement of Rs. 1,08,025/-. It is stated that from the discharge summary issued by Desun Hospital, it is revealed that during her admission in the said hospital the mother of the complainant was neither treated for hypertension nor any medicine was used to combat the disease of hypertension. According to the complainant the cause of denial of reimbursement on the ground of hypertension is nothing but an unfair trade practice. In spite of several requests, the O.P. neglected to reimburse the amount of Rs. 1,08,025/-. Hence the complaint, praying for directing the O.P. to reimburse an amount of Rs. 1,08,025/- to the complainant against the said policy along with statutory interest till realization and for an order of compensation and cost.
O.P. has contested this case by filing W/V.
Denying and disputing the case of the complainant, it is specific case of the O.P. that the complainant had taken the said mediclaim policy which was valid from 08.08.2013 to 07.08.2014 and it was continued from 08.08.2014 to 07.08.2015. The complainant after knowing all terms and condition of the policy, signed on the proposal form. It is stated that Pranati Ghosh, the mother of the complainant took admission on 06.08.2015 and she was discharged on 10.08.2015 from Desun Hospital and Heart Institute with a final diagnosis “other acute Ischaemic Heart Diseases, Essential (primary) Hypertension, Ulcer of lower limb, not elsewhere classified” and after that the policy holder sent a bill of Rs. 1,08,025/- along with other documents before the T.P.A. of the O.P. on 15.09.2015 for reimbursement. After going through the documents of the Hospital, the said T.P.A. repudiated the claim of the complainant. Complainant thereafter sent a letter to the O.P. against such repudiation. After receiving the report of Medical Assistant Insurance T.P.A. Pvt. Ltd. the O.P. observed that the repudiation of the claim by T.P.A. was justified and the reason of repudiation was due to beyond the terms and conditions of the Mediclaim Policy which the proposer signed at the time of taking the policy. It is further stated by the O.P. that under the exclusive clause under 4.3 (XVII) of the policy it has been clearly mentioned as “during the period of insurance coverage the expenses on treatment of hypertension for specified period of 2 (two) years are not payable, if contracted and / or menifestated during the currency of the policy. As per report of the T.P.A. the policy holder had a pre existing diseases under exclusion clause of 4.1 which the policy holder did not disclose at the time of taking the policy. It is therefore claimed by the O.P. that the repudiation of claim of the complainant was justified and the petition of complaint is therefore liable to be dismissed.
To prove their respective case, both sides have tendered their written examination-in-chief supported by affidavit in evidence and they also filed questionnaire and reply against such evidence.
POINTS FOR DECISION
- Is the case maintainable in this present form and prayer?
- Is the complainant a consumer of the O.P.?
- Is there deficiency in service or unfair trade practices on the part of the O.P.?
- Is the complainant entitled to get the reliefs, as prayed for?
DECISION WITH REASONS
Point No. 1 : Maintainability of this case has not been questioned by any of the parties at the time of final hearing of this case. We also find anything adverse regarding maintainability of this case.
This point is therefore decided in the affirmative and in favour of the complainant.
Point No. 2 : It is not denied and disputed that the complainant obtained a Happy Family Floater Policy from the O.P. – Insurance Company and the dispute of this case relates to reimbursement of mediclaim in respect of that policy. So, the complainant is definitely a consumer of the O.P. – Insurance Company.
Point No. 3 : By filing the present complaint, the complainant has alleged that the O.P. – Insurance Company has caused deficiency in service and unfair trade practice by repudiating her claim of medical reimbursement of the policy in question.
Admittedly the complainant obtained a Happy Family Floating Policy being Policy No. 311400/48/2014/3083 from the O.P. on 08.08.2013 and the same was renewed till 08.08.2017. In the said policy, the complainant was a proposer of her husband Sumit Kumar Bose, her son Satyaki Basu and her mother Pranati Ghosh. It is not disputed and denied that during the said policy period, Smt. Pranati Ghosh, the mother of the complainant, was admitted by the complainant in the emergency department of Desun Hospital and Heart Institute at E.M. Bypass, Kasba Golpark, Kolkata – 700 107 and after her treatment there, she was discharged from the said Hospital on 10.08.2015. After such discharge, the complainant submitted all medical papers of such treatment along with Mediclaim Form on 14.09.2015 before the O.P. in order to get reimbursement of an amount of Rs. 1,08,025/-. Admittedly after considering the report of T.P.A., the O.P. repudiated such claim of medical reimbursement. Now the question arises as to whether such repudiation was done by the O.P. – Insurance Company rightly or wrongly.
It appears from the written version of the O.P. that from the medical papers submitted by the complainant it was observed by their T.P.A. that it was diagnosed as a case of Acute Coronary Syndrome, Hypertension (HTN) with Ischaemic Non Healing Ulcer over right limb. Under the exclusion of clause 4.3 (XVII) it has been clearly mentioned that “during the period of insurance coverage the expenses of treatment of hypertension for specified period of 2 (two) years are not payable”. Further according to the O.P., the report of their T.P.A. discloses that the mother of the complainant had a pre- existing disease under exclusion clause of 4.1 which the policy holder did not disclose at the time of taking the policy.
Admittedly during policy period of 2 (two) years, the mother of the complainant was admitted in the said Hospital on 06.08.2015. From the discharge summary of Desun Hospital and Heart Institute, so filed by the complainant, it appears that the mother of the complainant Smt. Pranati Ghosh was diagnosed and treated for Acute Coronary Syndrome, Hypertension and Ischaemic Non Healing Ulcer over right limb. From clause 4.3 (XVII) of the policy in question we find that the expenses on treatment of hypertension is not payable during the period of 2 (two) years.
Therefore as per terms and conditions of the policy in question and in view of clause 4.3 (XVII) of the policy, the complainant is not entitled to get reimbursement of mediclaim of her mother who was treated for hypertension and other disease. The O.P. – Insurance Company therefore rightly repudiated the claim of insurance and they did no deficiency in service in repudiating such claim of insurance.
This point is accordingly decided in favour of the O.P. and against the complainant.
Point No. 4 : In view of our above finding under point no.-3, the complainant is not entitled to get any reliefs as prayed for.
All the points are accordingly disposed of.
In the result, the complaint case fails.
Hence,
it is,
O R D E R E D
that the Complaint Case No. 161/2017 is dismissed on contest but in the circumstances without any cost.
Let plain copy of this order be given to the complainant free of cost.
Dictated and corrected by me.
( Bibekananda Pramanik )
President, D.C.D.R.F., Howrah.
