State Consumer Disputes Redressal Commission
The Div. Manager, Oriental Insurance ... vs Sri Alok Kumar Ghosh on 8 April, 2010
State Consumer Disputes Redressal Commission State Consumer Disputes Redressal Commission West Bengal BHABANI BHAVAN (GROUND FLOOR) 31, BELVEDERE ROAD, ALIPORE KOLKATA 700 027 S.C. CASE NO. FA/37/10 DATE OF FILING: 21.01.2010 DATE OF FINAL ORDER: 08.04.2010 APPELLANT 1) Oriental Insurance Co. The Divisional Manager, Div-VI Kolkata, Everest House 2F 40C, Chowringee Road, P.S. Shakespeare Sarani Kolkata 700 071 2) Oriental Insurance Co. The Senior Divisional Manager, Div-III Kolkata, Thapar House 25, Biplabi Trailokya Maharaj Sarani P.S. Hare Street, Kolkata 700 001 3) Oriental Insurance Co. Regional Manager, Div-VI, Kolkata 4, Lyons Range, P.S. _ Hare Street Kolkata 700 001 RESPONDENT 1) Sri Alok Kumar Ghosh S/o Late Subodh Kumar Ghosh 42/82, New Ballygunge Road P.S. Kasba, Kolkata 700 039 2) The Finance Officer Jadavpur University 186, Raja S.C. Mullick Road Jadavpur, P.S. Jadavpur Kolkata 700 032 3) Paramount Health Services Ltd. ICMARD Building, 8th floor 14/2, CIT Road, Scheme VIII M, Ultadanga, P.S. Phoolbagan Kolkata 700 087 BEFORE : HONBLE JUSTICE MR. A. CHAKRABARTI, PRESIDENT MEMBER : MRS. S. MAJUMDER FOR THE APPELLANT : Mr. S. Nayak, Advocate FOR THE RESPONDENT : Mr. P. Basu, Advocate : O R D E R :
HONBLE JUSTICE MR. A. CHAKRABARTI, PRESIDENT This appeal is against order dated 24.12.09 passed by District Consumer Disputes Redressal Forum, Kolkata Unit-I in case no.169/08 whereby the complaint was allowed directing payment of Rs.1,66,544/- to the complainant as cost incurred by the policy holder for implanting pace-maker and Rs.15,000/- as compensation and Rs.5,000/- as cost. OPs were also directed to pay unpaid cost of Rs.8,000/-.
The case of the complainant is that he obtained Group Mediclaim Policy covering himself, his son and wife from Oriental Insurance Company from 1st March, 1999 renewable every year.
The proposal for the said policy was accepted after disclosure of all material facts including the fact that the complainant was carrying a pace-maker as per advice of the doctor which was implanted on 04.01.92. The policy was renewed from time to time. As per advice of the doctor the complainant had to undergo replacement of the pace-maker during the period from 02.7.07 to 05.7.07 at Woodland Nursing Home with an expenditure of Rs.1,83,944.85. A part of the expenditure being Rs.17,400/- was realized by the complainant from GIC. On claim of the amount the OP2 refused to reimburse the amount and accordingly the present complaint was filed praying for Rs.1,66,544/- as also Rs.1 lac as compensation and litigation cost of Rs.1 lac.
The Insurance Company filed written statement.
The Insurer stated that it repudiated the claim referring to the exclusion clause no.4.1 which stated that all diseases/injuries which are pre-existing where the cover incepts for the first time.
For the purpose of applying this condition, the date of inception of the initial medicalim policy taken from any of the Indian Insurance Company shall be taken into account provided the renewals have been continuous and without any break.
Heard Mr. S. Nayak, the Ld. Advocate for the Appellant who contended that replacement of the whole or part of the pace-maker is not covered in the policy and the insured is not entitled to reimbursement for treatment of any pre-existing disease. Further contention was made that in respect of same item two different claims are not maintainable.
Mr. P. Basu, the Ld. Advocate for the Complainant/Respondent that the claim was made neither for any pre-existing disease nor for replacement of pace-maker could be refused applying the conditions governing the agreement of insurance.
After considering the respective contentions I have considered the condition no.1 contained in the Memorandum of Understanding enclosed to the written version of the OPs which were relied on by Mr. Nayak, the Ld. Advocate for the Insurer justifying refusal of the claim. The said condition excludes by pre-existing diseases from the purview of the coverage. It is not denied by the Insurer that the complainant was carrying a pace-maker from 1992 was duly disclosed at the proposal stage and taking the same into consideration policy was issued. Moreover, Mr. Nayak, the Ld. Advocate could not show any provision which entitles the insurance to refuse claim on account of replacement of a pace-maker or against claim from two insurers when claim granted by one insurer has been excluded from the claim from the other insurer.
In the circumstances I do not find any ground for interference with the impugned judgment and, therefore, the appeal fails and is hereby dismissed.
(S. Majumder) (Justice A. Chakrabarti) MEMBER(L) PRESIDENT