DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

WEST TRIPURA :  AGARTALA

 

CASE   NO:   CC- 326  of  2022

 

 

Smt. Sumita Chakraborty,

W/O- Sri Sankar Lal Chakraborty,

Ramnagar Road No.8,

P.O. Ramnagar, P.S. West Agartala,

District- West Tripura-799002. …...............Complainant.

 

 

-VERSUS-

 

 

1. The Senior Manager, 

Punjab National Bank,

4, Mantribari Road, Agartala, 

West Tripura- 799001.

 

2. The Oriental Insurance Company Ltd.,

Having its Registered office at Oriental House

at P.B. No. 7037, A- 25/27, Asaf Ali Road,

New Delhi- 110002, 7899001.

 

3. The Divisional Manager,

Oriental Insurance Company,

H.G. Basak Road,

P.O. Agartala, P.S. West Agartala, 

District- West Tripura.

 

4. The Medi Assist Insurance TPA Pvt. Ltd.,

(Formerly Known at Medi Assist India Pvt. Ltd.)

CINU85199KA1999PTC025676,

Registered Office Tower “D”, 

4th Floor, IBC Knowledge Park, 

4/1 Bannerghatta Road,

Bangalore- 560029. …...................Opposite Parties.

 

 

 

 

  

 

  __________PRESENT__________

 

 SRI GOUTAM DEBNATH

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 Haradhan Sarkar,

  Sri Victor Ghosh,

  Saikat Rahman,

  Sri Sankar Lal Chakraborty,

  Sri Manojit Das,

  Learned Advocates. 

 

For the O.P. No.1 : Sri Loknath Datta,

  Learned Advocate.

 

For the O.P. No. 2, 3 

& 4 : Sri P.K. Debnath,

  Learned Advocate. 

 

 

 

 

ORDER   DELIVERED  ON: 29.04.2023.

 

 

F I N A L    O R D E R

1. This case is filed U/S 35 of the Consumer Protection Act, 2019 by Smt. Sumita Chakraborty of Ramnagar, Agartala (in short the 'Complainant') against the O.Ps, namely (i)The Senior Manager, Punjab National Bank, Agartala(in short 'O.P. No.1'), (ii)The Oriental Insurance Company Ltd., New Delhi(in short 'O.P. No.2'), (iii)The Divisional Manager, Oriental Insurance Co. Ltd., Agartala(in short 'O.P. No.3'), (iv)The Medi Assist Insurance TPA Pvt. Ltd., Bangalore(in short 'O.P. No.4') alleging deficiency in service on the part of the O.Ps.

1.2 The case of the complainant in brief is that the complainant being holder of an account in the Punjab National Bank, Agartala purchased a PNB-Oriental Insurance Mediclaim Policy.

1.3 On 09.02.2021 the complainant was admitted in the Apollo Hospital, Chennai with pain on knees and underwent medical treatment and was discharged on 12.02.2021. An amount of Rs.5,16,101/-was incurred  for the treatment purpose. 

1.4 Thereafter on 03.03.2021 the complainant applied to the Senior Manager, Punjab National Bank, Agartala claiming reimbursement of the bill amount of Rs.5,16,101/-. 

1.5 On 25.03.2021 Insurance Authority asked to raise claim in proper claim form with all necessary documents. 

1.6 Thereafter on 08.04.2021 O.P. No.3 asked for more documents which was replied on 19.04.2021 that all documents already submitted through speed post.

1.7 The complainant after that also deposited premium continuing his mediclaim policy for the period from 19.07.2021 to 18.07.2022. The O.P. claimed Rs.12,702/- as policy premium for the period from 19.07.2021 to 18.07.2022 instead of previous policy premium @ Rs.5,281/-. However, the complainant claimed excess payment of Rs.7,421/- and prayed to continue to pay Rs.5,281/- like previous years.

1.8 However, the claim of the complainant was not settled by the O.Ps.

1.9 Hence, the complainant filed this case claiming Rs.5,16,101/-, cost of his treatment, Rs.50,000/- for harassment and mental agony, Rs.7,421/-, extra premium charge, in total Rs.5,73,522/-  with 7% interest.

 

2. O.Ps contested the case by filing their respective written versions against the complaint filed by the complainant.

2.1 O.P. No.1, Punjab National Bank in their written version have stated that they have communicated the claim to the Insurance Authority and sent the record submitted by the claimant to the Insurance Authority.

2.2 It is also contended by the O.P. No.1 that  bank has no liability as the Bank was only Agent of the Insurance company and the O.P. No.2, 3 & 4 are liable to pay the medical reimbursement as per IRDA Rules.   

2.3 The O.P. No.2 & 3 refuted the statement  made by the complainant in his complaint petition and stated that premium of Rs.5281/- as well as excess premium of Rs.7421/-  are not correct and premium was taken as per norms. 

2.4 It is also submitted by the O.P. Insurance company that the expenditure of Rs.5,73,522/- are subject to assessment by TPA Medi Assist Insurance Pvt. Ltd., Bangalore, O.P. No.4. As per insurance norms waiting period is 3 years for Osteoarthritis and operation was done on 09.02.2021 and policy commenced on 05.07.2018. As such the claim is not admissible.

 

3. Complainant filed her evidence on affidavit and also submitted medical documents, premium receipt, copy of policy & letter dated 23.08.2021.

3.1 One Gopal Krishan, Divisional Manager, Oriental Insurance Co. Ltd. have filed his evidence on affidavit. 

We have heard argument of the parties.

 

4. On the basis of the pleadings, documents filed by both side following points emerged for discussion and decision:-

(i) Whether there is any deficiency in service on the part of the O.Ps?

(ii) Whether as per the Policy the complainant is entitled to get the medical reimbursement along with compensation?

 

DECISION AND REASONS FOR ECISION:-

5. Both the points are taken up together for convenience. 

5.1 We have gone through the documents on record. First Policy was commenced from 05.07.2018 to 04.07.2019, 2nd policy was from 15.07.2019 to  14.07.2020 and 3rd policy was from 15.07.2020 to 14.07.2021 mentioning the previous policy numbers. 

5.2 Exclusion period for 3 years is not correct as per Exclusion clause 3 (f) because, serial no. (xxiv) age related Osteoarthritis and osteoporosis is not applicable as there is nothing in the medical report that it is an age related disease and the claimant was only 52 years plus old.

 

5.3 Clause (v) for two years is also not applicable as the disease was not manifested after inception of first policy which continued from 05.07.2018. On the top of it generally there is a grace period of 15 days to renew policy and some companies give 30 days also. 

5.4 However,  under clause 2 (j) serial No. 2 total coverage is Rs.1,10,000/-(0ne lakh Ten Thousand only) and the complainant spent Rs.5,16,101/-. 

5.5 In the 3rd policy 15.07.2020 to 14.07.2021 previous policy number not mentioned. Means it was not a case of renewal of policy. Rather, it was a new policy. Hence, as per Learned counsel of the O.P. waiting period is attracted. Hence, not entitled to reimbursement.  

5.6 As per clause 3 (f) serial no. (v) Non-infective Arthritis waiting period is 2 years and under clause 3 (f)  (xxiv) age related osteoarthritis and osteoporosis waiting period is 3 years.

5.7 The complainant was 55 years 1 month 11 days old at the time of her admission in the hospital. She was diagnosed as osteoarthritis both knees as per the discharge summary. So neither the complainant suffered from non-effective Arthritis as per clause 3 (f) (v) or age related osteoarthritis and osteoporosis as per clause 3(f) (xxiv) of the policy. The complainant was only 55 years old not even a senior citizen to say age related disease. 

5.8 1st policy from 05.07.2018 to 04.07.2019, 2nd policy from 15.07.2019 to 14.07.2020 wherein previous policy number mentioned. 3rd Policy from 15.07.2020 to 14.07.2021 but previous policy number not mentioned to show that it was a new policy but not renewal of earlier policy from 15.07.2019 to 14.07.2020 although the previous policy was valid till the midnight of 14.07.2020 and the policy holder paid premium on the next on 15.07.2020. Was it possible to obtain the policy in the late night of 14.07.2020? It is either a trick on the part of the Insurance Co. or a blunt mistake on the part of the Insurance Company. So, we find no merit in the argument that it was not a continuation of policy and for that a fresh compulsory waiting period started from 15.07.2020 or even waiting period as per exclusion clause is attracted.

 

6. As a corollary to the discussion above the points are decided in the affirmative and against the O.P. Insurance company. 

 

7. Final bill of the hospital shows Rs.4,97,884.00 was spent. However, total sum insured as per the policy for 15.07.2020 to 14.07.2021 was Rs. 2 lakhs only. Hence, the complainant is entitled to get the sum insured of Rs.2 lakhs only.

 

8. In the result, it is ordered that the O.P. Insurance company shall pay Rs.2 lakhs to the claimant with an additional sum of Rs.30,000/- as compensation including litigation cost for their deficiency in service. Both these amounts shall carry interest @ 7.5% P.A. from the date of filing the complaint i.e., 24.02.2022 till the date of actual payment unless paid within 30 days from today.

 

 

 

9. The case stands disposed off. Supply a copy of this Final Order free of cost to all the parties. 

 

 

 Announced.

 

 

 

 

SRI  GOUTAM DEBNATH

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.