JUDGEMENT

            Initially complainant Dr. Ratna Chanda by filing this complaint submitted that she had her one insurance policy valid for the period from 17.01.2009 to 16.01.2010 having policy No. 030600/48/08/0000/489 covering Mediclaim of his son namely Dibya Ghosh and the policy is named as individual health insurance policy and after getting the policy number, the complainant and her son were unused under the United India Insurance Co. Ltd under Medi-Claim policy.

          Further it is submitted that on 09.11.2009 complainant was admitted at AMRI Hospital with the decease of cough SOB Asetis, Pedal, Oedema and non alcoholic CIRRHOSIS of lever and thereafter the complainant was discharged from the hospital on 21.11.2009 and about her admission the matter was reported to Insurance Co. during her stay in the hospital and agent of the Insurance Co. went to the hospital made necessary inspection in regard to her admission.  After that on 13.11.2009, the complainant was served with letter of the op insurance company intimating that an amount of Rs.33,250/- had been sanctioned as Medi-Claim to the complainant.  But complainant was under impression that the entire expenditure will be borne by the Insurance Co.  But on 19.11.2009 the insurance company issued a letter in favour of the complainant stating that the sanctioned amount of Rs.33,250/- had been cancelled without any cogent reason.

          In the above situation, complainant sent a letter to the insurance company on 06.01.2010 requesting them to make payment of total expenditure of Rs.1,00,454.79/- within 15 days.

          Thereafter on 12.01.2010 to the Administrative Officer of the Insurance Co. issued a letter to M.D. Indian Health Care Services (TPA) Pvt. Ltd. asking them on what basis they sanctioned the amount of Rs.33,250/- and give reasons for the denial of the same and on receiving the letter,  Advocate for the complainant wrote another letter to the Administrative Officer of the insurance company to make payment of the total claim of Rs.1,00,454.79/- and in fact complainant is entitled to get total amount and also damages amounting to Rs.10,00,000/- for causing harassment, mental pain, suffering and for denying of the insurance mediclaim.

          During the pendency of this case Dr. Ratna Chanda died and one Dibya Guha added as party vide order dated 04.02.2011. 

          On the other hand the Insurance Co. by filing this written statement submitted that practically at the time of purchasing this policy, complainant did not disclose her pre-existing disease and admitted fact is that complainant within 10 months of taking the policy was admitted to the hospital for chronic lever dysfunction, Oedema and CIRRHOSIS of Lever along with other complication and accordingly the claim was repudiated under Clause 4.1 of Insurance Contract.  Further submitted that chronic lever dysfunction cannot happen within a short span and for which relying upon the web page web M.D. particularly CIRRHOSIS of lever it is found that complication of lever due to fatty lever associated with obesity and Diabeties and also for chronic viral lever (Hepatitis-B,C & D) and for other reason and so it was detected after considering the medical report that prior to purchasing the present policy she had her several type of diseases like Hepatitis, Diabeties and other cystic fibrosis etc and so the said claim was repudiated for non disclosure of the entire material and for which the present claim is not tenable.

                                              Decision with reasons

          After proper study of the complaint and particularly the date of filing of this complaint on 11.05.2010 by Dr. Ratna Chanda the complainant and her death on 02.09.2010 at Cure Centre Nursing Home it is found that Ratna Chanda was also known as Ratna Guha.  So, her son is knows as Dibya Guha.

          From the copy of the Insurance Policy, it is found that it was valid from 17.01.2009 to 16.01.2010 and in the said policy it is specifically noted that pre existing illness are excluded from scope of policy subject to condition norm of the policy and name of the insured were two persons Dibya Guha and Ratna Chanda (son & mother).

          After considering the treatment summary of AMRI Hospital, it is found that Dr. Ratna Chanda was hospitalized at AMRI Hospital on 09.11.2009 and she was discharged on 21.11.2009 and no doubt policy was started on and from 17.01.2009 with expiry date 16.01.2010 and fact remains during that period she became ill and was hostipalised at AMRI Hospital on 09.11.2009 and from the said treatment sheet it is found that on the date of admission her age was about 58 years with present history CIRRHOSIS of lever and abdomen distended with brief history and other medical reports are not filed by the complainant in this case.  But fact remains bill was submitted by the Hospital authority for a sum of Rs.1,00,454.79/- and on the basis of that op TPA initially sanctioned a sum of Rs.33,250/-.  But subsequently, that was cancelled but reason of cancellation is not here and there but subsequently op in their written statement has submitted that it was cancelled because after verifying all medical reports all the diseases were pre existing which was of such a nature that may death.

          No doubt Ld. Lawyer for the op submitted when part amount of Rs.33,250/- was allowed then invariably at the relevant time TPA considered all the documents which were sent by the Hospital Authority.  Then there was no scope to cancel the same and another factor is that the higher authority of the insurance company of TPA asked the TPA Authority for what reason the said amount was sanctioned and for what reason it was cancelled .  But in this regard TPA was silent.  Further fact is that after purchase the insurance mediclaim policy then and there she did not fall ill but after lapse of nine months she was admitted to AMRI Hospital on 09.11.2009 with cough with SOB, Pedal Oedema and she was treated and there was also Oesophagealvarix and on treatment by medicine she recovered and fact remains at that time it was detected that she suffered from CIRRHOSIS of lever with PHTM, Ascitis.  But prior to that the complainant was suffering from pre existing disease has not been proved by the op by any means or by producing any documents and fact remains as per National Institute of Health CIRRHOSIS of lever is the 12^th leading cause of death by disease.  But in the present case, she had not been suffering from Hepatitis or there was no anti-trypsin deficiency that is an absence of specific enzyme in the lever but mere disease caused by abnormal lever function cannot be treated as CIRRHOSIS for a long period always and long period is not required for developing such a disease of CIRRHOSIS.  But after study of the website as supplied by the op it is found that due to parasitic infection also CIRRHOSIS of lever may be caused and from the present report of the patient issued by AMRI Hospital it is found that complainant was admitted to AMRI Hospital with a history of cough with SOB, Asecitis, Pedal Oedema and for her treatment antibiotic, steroid medicines were used for treatment and further she was suffering from osephegervarik and practically she recovered and was discharged on 21.09.2009.  But in this regard we have gone through another medical journal of National Institute of Health, wherefrom we have gathered that sometimes due to reaction of prescriptive drugs prolong exposure to environmental toxin or para-cystic infection, CIRRHOSIS of lever may be developed and considering that opinion and also the present medical treatment summary Annexure-B, we have gathered that there was no pre existing disease of the complainant of Ratna Chanda.  But practically due to sudden infection and for using steroid drugs she suffered from CIRRHOSIS of lever may be caused for various reasons but in the present case it was not due to any sort of diseases like Hepatitis-B, C etc. and further from the medical report it is found that she had not been suffering from any absence of any specific enzyme in her lever.  So, considering all the above fact and materials and medical theorization of CIRRHOSIS of lever of different another and National Institute of Health we are convinced to hold that Ratna Chanda had not been suffering from any pre existing disease preceding to the purchasing the present policy and after purchasing the same for 9 months she had no problem but suddenly she was attacked with cough with SOB Asecitis Pedal Oedema, Osephegenvarik etc and for which she was admitted and she was in the hospital only for 11 days and was discharged on 21.09.2009.  But truth is that she died on 02.09.2010 i.e. after lapse of another 11 months.  So we are convinced to hold that the allegation of the ops that she had been suffering from pre existing disease prior to purchasing the policy is proved a false story and as per settled principle of law it is the duty of the ops (Insurance Co. or TPA) to prove by producing document that she had been repeatedly admitted and treated for several type of diseases but that is absent but no such paper is produced by the op for which we are convinced to hold that rejection of the claim of the complainant on the ground of pre existing disease is completely baseless and without any foundation.

          Another factor is that as per insurance policy complainant was entitled to Rs.1,00,000/- as sum assured on the basis of the present policy in respect of which mediclaim was submitted and as per contract op is bound to pay only Rs.1,00,000/- but not more than that because that is contract of the present policy.  So, in view of the above finding we are of opinion that complainant is entitled to Rs.1,00,000/- as mediclaim against the present policy in respect of her treatment from the op Insurance Company and op Insurance Co. is bound to pay it to the complainant’s son Dibya Guha(Ghosh) the substituted complainant as he is the only son of Ratna Guha (Chanda) and further op Insurance Co. is also bound to pay the compensation of Rs.25,000/- over the said amount because op rejected the claim of an aged lady without considering the other materials and only drawing inference from the present treatment.

          Op Insurance Co. is directed to pay Rs.1,25,000/- in total to the complainant.

          Accordingly, the complaint succeeds.

          Hence, it is

                                                          ORDERED

          That the complaint be and the same is allowed on contest against the Insurance Co./ops with a cost of Rs.10,000/-.

          Ops are directed jointly or severally to pay a sum of Rs.1,00,000/- as Medi-Claim Insurance and Rs.25,000/- as compensation that is total Rs.1,25,000/- and also the litigation cost of Rs.10,000/- i.e. total Rs.1,35,000/- to Sri Dibya Guha, the son of diseased Dr. Ratna Guha within one month from the date of this order failing which for each day’s delay punitive damages @ Rs.500/- per day shall be paid by the op Insurance Co. and said punitive damages shall be paid to the State Consumer Welfare Fund till full satisfaction of the decretal amount and even if the ops violates the Forum’s order in that case penal measure shall be taken against them and further penalty of Rs.10,000/- shall be assessed and charge and imposed for violation of the Forum’s order.