State Consumer Disputes Redressal Commission
The Divisional Manager, New India ... vs Smt. Chhanda Chakraborti, Wife Of Late ... on 5 May, 2014
State Consumer Disputes Redressal Commission State Consumer Disputes Redressal Commission West Bengal 11A, MIRZA GHALIB STREET, KOLKATA 700 087 S.C. CASE NO FA/239/2013 (Arisen out of Order Dated 31.12.2012 in Case No.CC/380/2010 of District Unit-I, Kolkata DF) DATE OF FILING :01.03.2013 DATE OF ORDER:05.05.2014 APPELLANT : The Divisional Manager, New India Assurance Company Ltd., having his office at 18/2, Gariahat Road, P.S.-Gariahat, Kolkata 700 019 RESPONDENTS(SUBSTITUTED) : 1A) Smt. Chhanda Chakraborti, Wife of Late Sambhunath Chakraborty, A/15,Poddar Nagar (No.2), P.G.H. Shah Road, P.O. and P.S. Jadavpur, Kolkata-700032. 1B). Sri Shantanu Chakraborti, A/15, Poddar Nagar (No.2), P.G.H. Shah Road, P.O. and P.S. Jadavpur, Kolkata-700032. 2. E-Meditec(TPA) Services Ltd., having its branch PROFORMA RESPONDENTS office at 230A, A.J.C. Bose Road Chitrakut Building, 2nd Floor, Kolkata 700 020. 3. Dr. Biplab Saha, E-Meditec (TPA) Services Ltd., having its branch office at 230A, A.J.C Bose Road, Chitrakut Building, 2nd Floor, Kolkata-700 020. BEFORE HONBLE MEMBER : Sri Debasis Bhattacharya. HONBLE MEMBER : Sri Jagannath Bag. FOR THE APPELLANT : Mr. Sandip Ghosh, Ld. Advocate FOR THE RESPONDENT : Mr. Indrajit Biswas, Ld. Advocate. Sri Debasis Bhattacharya , Member
This appeal is directed against the order dated 31.12.2012 passed by the Ld. District Forum, Unit-I, Kolkata in Case No. 380/2010.
The case of the Complainant, in short, is that he is a retired Government servant, aged about 72 years, and a senior citizen. He purchased Mediclaim policy of the OP Nos. 1 & 2, which commenced on 07.05.1997 and renewed thereafter and for the relevant years, 2009-2010, the OP No.2 issued policy certificate bearing no. 610600/34/09/1100000476 of a sum assured of Rs.1,00,000/-. On 17.07.2009, he was admitted to Sri Aurobinda Seva Kendra, Kolkata with symptoms of vomiting, nausea, respiratory problems, chest pain and was under the treatment of Dr. Saumitra Roy, MD ( Cal), MRCP (UK), FRCP (Edin), a Cardiologist. He was treated, inter alia, for LVF, Dyselerolytemia, Hypertension and Chronic Obstructive Pulmonary Disease, and was discharged on 23.07.2009. He submitted a claim of Rs.32,949/- on account of hospitalization expenses in the prescribed form, supported by original relevant documents, bills and vouchers, with the OP No.3, being the agent of the OP Nos. 1 & 2, on 04.09.2009. By a letter dated 16.11.2009, the OP No.4, on behalf of the OP No.3, repudiated the claim with the observation that as per discharge summary, the patient admitted with H/O taking analgesic for dental pain, so as per Cl. No. 4.4.5 & 4.5.6 of the N.I.A.C., the claim was rejected. Accordingly, he referred the matter to the Dr. Saumitra Roy, and after obtaining the expert opinion, he filed a letter of appeal on 15.02.2009 to the OP No.2, with copy to the OP No.3. But, despite repeated reminders over phone and personal visits to the offices of the OP No.2 & 3, no action was taken to settle the claim. He also filed a complaint before the Insurance Ombudsman on 12.07.2010, but no action was taken within a reasonable time. Accordingly, the case.
On the other hand, the case of the OP No.2, who only contested the case before the Ld. District Forum, is that the Complainant took the hospitalization benefit policy, Mediclaim Policy (2007) under the OP No.2 for the period from 07.05.2009 to 06.05.2010, Policy No. 510600/34/09/11/00000476 for a sum insured of Rs.50,000/- plus Rs.50,000/-. He submitted a claim of Rs.32,949/- for hospitalization at Sri Aurobinda Seva Kendra from 18.07.2009 to 23.07.2009 for acute gastritis with drug poisoning with post CABG & Dental Pain. As per the Discharge Summary, he was admitted with complaints of epigastic pain following intake of analgesic for dental pain, which means that he was admitted with the history of taking analgesic for dental pain. Thus, the proximate cause was dental pain, which is a permanent exclusion as per Exclusion Clause No. 4.4.5. Furthermore, the OP has already paid the maximum liability under the above policy of Rs.50,000/-. Thus, the TPA rightly repudiated the instant claim as per terms and conditions of the policy (2007). So, there is no deficiency in service. As such, the complaint be dismissed.
It is to be duly seen and considered whether the impugned order suffers from any kind of anomaly as to law and facts so as to make an interference therein.
Decision with reasons.
Ld. Advocate for the Appellant has submitted that there is an implicit case of dental pain in it. The case falls under the permanent Exclusion Clause No. 4.4.5. he further referred to Clause No.60 of the policy, in which it is mentioned that if the policy is to be renewed for enhanced sum, then restriction, i.e., 4.1, 4.2 and 4.3 will apply to additional sum insured as if it is a new policy. Accordingly, the repudiation is justified.
Ld. Advocate for the Substituted Respondents has submitted, who stepped into the shoes of the original Complainant in this appeal, has submitted that repudiation is only for dental pain, for which the whole claim was rejected, and the appeal subsequently made before the OP No.2 as per stipulation of the policy was not at all considered properly, nor the original Complainant got any order from the Insurance Ombudsman within a reasonable time. There is no case of any pre-existing disease in terms of Clause 4.1 of the Policy.
On a mere glance of the medical papers, it is crystal clear that the case does not at all fall within the category of dental pain so as to oust the proper claim of the Complainant, who was a highly senior citizen, by the misguided/misdirected TPA, and the appeal before the OP No.2 had fallen on deaf ears. It is a clear case of lackadaisical attitude of both the TPA and the New India Assurance Company Ltd. concerned. Either they could not make any sense of the Discharge Summary of the Sri Aurobinda Seva Kendra and the certificate issued by the Doctor concerned or remained extremely passive in attitude in considering the genuine claim of the Complainant. The case does not at all fall within the four corners of dental treatments as per Clause No. 4.4.5. There is no merit of any way in the repudiation. It is perfectly a case of callousness and apathy of the authorities that be, which warrants and calls for introspection. It is also a typical example of allergy of the persons concerned to give humane touch and consideration in granting the due claim of the insured. There is at all no suppression of fact by the Complainant. He was reasonably required to be reimbursed of the claim in toto in substantiation of his enhancement of the assured sum from Rs.50,000/- to Rs.1, 00,000/- Surprisingly, as stated in the affidavit-in-opposition of the OP No.2, the other two subsequent claims of the Complainant, one for treatment for the period from 24.07.2009 to 30.07.2009 and the other for the period from 12.11.2009 to 11.11.2009 were reimbursed by the OPs. It is a sheer case of mishandling of the matter and a cause for concern. So, the OP Nos. 1 @ 2 being the principals, are wholly liable in the matter. The Ld. District Forum has rightly found the case in favour of the Complainant and awarded compensation in favour of the Complainant.
It is a fit case where the appeal should be dismissed with an exemplary cost. The grounds relied in the appeal are not just and sufficient.
Hence, ORDERED that the appeal be and the same is dismissed on contest against the Respondent No.1 series with a cost of Rs.10,000/- and ex parte against the Proforma Respondents, without any cost. The impugned order is hereby affirmed.
Sd/- Sd/-
MEMBER MEMBER