THE PRESIDENT

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

WEST TRIPURA : AGARTALA

 

 

CASE No. CC- 18  of  2020

 

 

Sri Subha Sundar Saha,

Madhya Laxmi Bill,

P.O. & P.S. Bisalgarh, 

District- Sepahijala Tripura. …...................Complainant.

 

-VERSUS-

 

1. The Oriental Insurance Company Ltd.,

Represented by its

Divisional Manager,

Having its Divisional Office at 

48/B, HGB Road,P.O. Agartala, 

P.S. West Tripura, Tripura West.

Pin- 799001.

 

2. Divisional Manager,

The Oriental Insurance Company Ltd.,

Having its Divisional Office at Agartala, 

Tripura West, 

Pin- 799001.

 

3. The Branch Manager,

The Oriental Insurance Company Ltd.,

B.C Bisalgarh, Bisalgarh Central Road,

Office Code- 322791,

P.O. & P.S. Bisalgarh, 

District- Sepahijala,.

Tripura- 799102.

 

4. M/S Raksha Health Insurance TPA Pvt. Ltd..

15/5 Mathura Road, Faridabad, 

P.O. & P.S. Faridabad,

Pin- 121003. ..................Opposite Parties.

 

 

     __________PRESENT__________

 

 SRI RUHIDAS PAL

PRESIDENT,

  DISTRICT CONSUMER  

DISPUTES REDRESSAL COMMISSION

      WEST TRIPURA, AGARTALA. 

 

Dr (SMT) BINDU PAL

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL COMMISSION

  WEST TRIPURA,  AGARTALA.

 

SRI SAMIR GUPTA,

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL COMMISSION

  WEST TRIPURA,  AGARTALA.

 

 

C O U N S E L

 

For the Complainant : Sri Gouri Sankar Bhattacharjee,

  Sri Monoj Debnath,

  Learned Advocates.

    

For the O.Ps : Sri Prahlad Kr. Debnath,

  Learned Advocate.

 

 

 

 

JUDGMENT  DELIVERED  ON  :  18.10.2021

 

J U D G M E N T

The Complainant's case in short is that the complainant is a reputed businessman of Tripura. Having convinced with the demonstration of the Happy Family Floater 2015 policy schedule the claimant had taken Health Insurance Policy on 18.04.2015 vide Policy no- 322791/48/2016 from the agent of the Oriental Insurance Co. Ltd.(in short O.P.). O.P. renewed the said policy in the subsequent years after receipt of the premiums from the complainant. In the year 2017 ie., on 21.06.2017 complainant again had taken the said Health Insurance Policy and it was valid up to 20.06.2018. It is stated by the complainant that the O.P. Insurance Company floated the said insurance policy in collaboration with the third party assistance M/S Raksha Health Insurance TPA Pvt. Ltd. 15/5, Mathura Road, Faridabad. On 09.02.2018 the complainant went to Kolkata  as he was suffering from serious cardiac problem. There he was admitted in the nursing home namely ''Belle Vue Clinic'' and treated there.  On 12.02.2019 angioplasty was done on the claimant. And after angioplasty he was discharged from the nursing home on 15.02.2018. He had to pay Rs.1,82,300/- for the said treatment. After returning from Kolkata the complainant raised claim to the O.P. Oriental Insurance company Ltd. for the said treatment done at Kolkata. After receipt of the claim O.P. Insurance Company has taken a quite inquriy and investigation and on 10.04.2018 the claimant was asked for some query which has been filled up by the complainant.  On several occasions the complainant approached to the O.P. No.1 for settlement of the claim of the complainant but the O.P. was silent about the claim. Till date the O.Ps neither paid the claim amount to the claimant nor repudiated the claim of the complainant for any valid reason. Though the policy of the complainant was valid upto 20.06.2018 but the O.P is deliberately negligent and did not provide the assured service to the complainant. Finding no other alternative the complainant filed this complaint claiming compensation of Rs.5,00,000/- for being negligent and deficiency in service  on the part of the O.Ps.  

 

2. On the other hand O.P. appeared and filed written statement  denying all the allegation of the complainant. In the written statement it is stated that the the complaint petition is not maintainable in law and fact. There is no cause of action and jurisdiction in the instant complaint and bad for non-joinder of necessary and proper party. It is also stated by the O.P. that due to observance and fulfillment of requirements complied with by the life assured shall be  condition precedent to any liability of the insurance company to make any payment. The O.Ps are not liable to settle the claim and to indemnify the complainant and prayed for dismissal of the complaint. The O.Ps Oriental Insurance Company Ltd. also filed additional written statement. In the said written statement it is stated by the O.P. that the relevant policy was endorsed with the TPA(Third Party Administrator), the O.P. No.4 which is to settle the claim first on the basis of the medical papers and thus during the process of the settlement the O.P. No.4 had to collect all the medical papers and general exclusions of the policy conditions no.4(4.1) which states ''All pre-existing disease(whether treated/ untreated, declared or not declared in the proposal form), which are excluded upto 48 months  of the policy being inform as per condition no. 4.3. The expenses on treatment of following ailment/ disease / surgeries, if contacted and or manifested after inception of the first policy are not payable during the waiting period of 2 years. It is also stated by the O.P. that in the original consultation/ prescription of Dr. S.K. Biswas, Belle Vue Clinic dated 09.02.2018 submitted by the insured on 03.05.2018 TPA, the O.P. No.4 finds the ailemnts of HTN & Past medical history: Hypertension in discharge of said clinic dated 15.02.2018 as pre-existing disease/ ailments for which the waiting period as per condition was 2 years and the policy was effected from 21.06.2017 to 20.06.2018 and as such waiting period run up to 21.06.2018 to 20.06.2019. During hospital admission from 10.02.2018 to 15.02.2018 the patient presented with the said ailments and treatment done on the said sufferings and as per terms and norms of the instant policy such treatment can not be covered and as such complainant is not entitled to claim the expenses of treatment against such ailments yet to be covered after elapsing of 2 years of waiting period. So the claim of the complainant was repudiated on 19.03.2018 by the TPA due to such reason. It is stated by the O.P. that there is no deficiency of service on the part of them.

 

3. EVIDENCE ADDUCED BY THE PARTIES:-

The complainant submitted his examination in chief on affidavit and also additional examination in chief and some documents (15 nos). 

On the other hand O.Ps  also submitted examination in chief of one Sri Gopal Krishan, Divisional Manager, OICL, Agartala. They also filed documents which are marked as Exhibit-A Series.

 

4. POINTS TO BE DETERMINED: - 

(ii) Whether there is deficiency of service on the part of the O.Ps?

  (iii) Whether the complainant is entitled to get compensation/ relief as prayed for?

 

5. ARGUMENTS: - 

  On the date of argument complainant was absent but Learned Advocate Mr. P.K.Debnath was present for the O.P. We heard Mr. Debnath and he submitted that the complaint petition is not maintainable as per terms and condition of the policy. He further submitted that complainant has failed to prove his claim by way of adducing evidence. No documentary evidences was exhibited from the side of the complainant though they have submitted examination in chief. Mr. Debnath submitted that the original prescription of Dr. S.K. Biswas of Velle Vue Clinic dated 09.02.2018 submitted by the insured on 03.05.2018 to TPA, the O.P. No.4 finds that the insured having an ailment of HTN and past medical history as pre-existing disease for which the waiting period was 2 years and the policy was effecting from 21.06.2017 to 20.06.2018 and as such waiting period runs up to 21.06.2018 to 20.06.2019 and the duration of hospital admission was from 10.02.2018 to 15.02.2018. So, such ailments and treatment of ailment can not be covered and the complainant is not entitled to claim the expenses of treatment. Mr. Debnath further submitted that treatment expenses are not covered as per terms of policy and it was repudiated by TPA with valid reasons, there are no negligence and deficiency of service on the part of the O.Ps.

 

6. FINDINGS  AND  REASONS  FOR  DECISION:-

                   All the points are taken up together for convenience. We have gone through the pleadings, evidences and documents submitted from both sides. On perusal of the pleadings and evidences, we find that complainant failed to exhibit any document to prove his claim. This is a case  which are to be proved by way of documentary evidences and not by oral evidences only. On the date of argument claimant was absent. So, we do not find any rebuttal/ contra argument which was submitted from the side of the O.Ps. The witness namely Gopal Krihnan, Divisional Manager of the Oriental Insurance co. Ltd. in his examination in chief at Para-1 stated that the relevant policy was endorsed with the TPA, the O.P. No.4 which is to settled first on the basis of the medical papers and thus during the process of settlement the O.P. No.4 had to collect  all the medical papers and general exclusions of policy No.4(4.1) which states all pre-existing disease which are excluded up to 48 months of the policy being enforced as per condition no.4.3, the expenses of treatment of the ailment are not payable during waiting period as mentioned. 

 

7. We have carefully gone through the documentary evidences adduced by the O.Ps. On appreciation of the entire evidences, we are in the opinion that the complainant has failed to prove his case by adducing sufficient evidences and complainant is also not entitled to get any relief as per terms and conditions of the policy. Hence, complaint is rejected. No costs. Supply copy of the judgment to both the parties free of costs.

 

Announced.

 

 

SRI R. PAL

PRESIDENT, 

DISTRICT CONSUMER  

DISPUTES REDRESSAL COMMISSION,

WEST TRIPURA, AGARTALA. 

 

 

 

Dr (SMT) B. PAL

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL COMMISSION, 

  WEST TRIPURA,  AGARTALA.

 

 

SRI SAMIR GUPTA,

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL COMMISSION

  WEST TRIPURA,  AGARTALA.