PRESIDENT DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR
CONSUMER COMPLAINT NO. 73/2022
Present-Dr. Ramakanta Satapathy, President,
Sri. Sadananda Tripathy, Member,
Sri. Shyam Dora,
S/O- Late Sagar Dora,
R/O- at Dora Complex, Opposite of Shivlok Complex, Gaiety Talkies Road,
Ps-Town, Po/Tahasil & Dist-Sambalpur,
Odisha-768001. ...………..Complainant
Versus
- The Branch Manager, Manipal Cigna Health Insurance Co. Ltd. Bhubaneswar Branch, Road No. 3, 2nd Floor of Dindayal Bhawan, Ashok Nagar,
Unit No.2, Bhubaneswar, Dist-Khurda
- The Branch Manager, Bank of Maharashtra,
At-Upper Ground Floor Shivlok Complex
Gaiety Talkies, Near GolBazar,
Dist-Sambalpur-768001. …………...Opp.Parties
Counsels:-
- For the Complainant :- Sri. H.N. Sarangi & Associates
- For the O.P. No.1 :- Sri. A.K. Sahoo & Associates
- For the O.P. No.2 :- None
Date of Filing:26.09.2022,Date of Hearing :11.12.2023,Date of Judgement : 05.02.2024
Presented by Dr. Ramakanta Satapathy, PRESIDENT
- The case of the Complainant is that the Complainant is having an A/C No. 68015223823 with O.P. no.2 and on the advice of O.P. No.2 policy No. 100200020617 and group policy No. 100200000100/00/00 on payment of Rs. 3980/- was taken on 02.05.2018 for self and wife Santosini Dora. Further mandate of auto-debit service was given for renewal of policy.
During 2021 the premium of health policy increased to Rs. 13,002/- and deducted from the account through after debit service on 03.05.2021. In August, 2021 the Complainant developed a lung infection called B/L pleural effusion. As no facilities were available in Sambalpur the Complainant was admitted in Gleneagles Global Hospital, Hyderabad as indoor patient on 26.08.2021 and discharged on 05.09.2021 and borne expenditure of Rs. 4,22,817/- Rs. 20,000/- expenditure made to-wards fare charges and cost of attendants. Claim was lodged with O.P. No.1 with originals but it was rejected and Xerox copies were returned. The O.P. No.1 is deficient in service rejecting the claim.
- The O.P. No.1 insurer in version submitted that for non-disclosure of facts the claim has been repudiated. The Complainant had history of surgical gastro consultation taken for swelling on the back 10-15 years back was not disclosed in proposal form at the time of inception. There is no any deficiency on the part of the O.P. No.1, insurer nor there is any unfair trade practice.
During free look period no any objection has been raised by the Complainant. The Complainant has violated clause VI of the policy term. In the family floater policy sum insured is Rs. 2.00 lakhs bearing policy No. 1002000020617.
Claim form No. 27024833 the Complainant was seeking reimbursement of medical expenses for the disease “Left loculated empyema”. After scrutiny of papers it was revealed that from discharge summary, the Complainant was suffering from history of surgical gastro consultation for 10-15 years back prior to proposal for insurance which was suppressed although specific question was there. The denial letter was issued on 25.02.2022. The O.P. No.1 is not liable for the claim.
- Perused the documents filed by the Complainant and O.Ps. The Complainant has filed Bank Statement dated 02.05.2018 payment of premium Rs. 3980/-. On 02.05.2019, 02.05.2020 & 03.05.2021 premium has been taken by O.P. No.1, insurer. The Complainant has filed rejected claim form copy for policy No. undergone B/L pleural affusion in Gleneagles Global Hospital and in this regard treatment details have been submitted. Final bill of Rs. 4,22,817/- has been paid to the hospital from discharge summary it reveals that from 26.08.2021 to 05.09.2021 the Complainant was in the hospital as indoor patient and left thoracotomy with de-cortication done on 31.08.2021.
The O.P. No.1 filed the enrolment form for customers of Bank of Maharastra, Certificate of Insurance, Premium Certificate, Pro-Health Insurance Policy and Certificate with Premium Certificate claim form, hospital IP No. 26082169875 wherein it has been mentioned that Surgical gestro consultation was taken for swelling on the back (inter scapsular region) since 10-15 years, & denial letter dated 25.02.2022, on the ground clause VI.1. Duty of disclosure.
- This is a mediclaim policy and the policy is continuing since 2018 and in the meanwhile policy premium has been raised from Rs. 3980/- to Rs, 13,002/-. Due to lungs infection the Complainant has made expenditure of Rs. 4,22,817/- and the O.P. No.1 denied for claim disbursement on the ground of pre-existing disease and non-disclosure of material facts. It is true that insurance agreement is bilateral agreement with utmost good faith entered by the insurer and insured. The insurer continued the policy till 2022 and when claim was made raised the question of the pre-existing disease. From 2018 till 2022 no any objection on policy has been made by insurer. Secondly, for the disease “LEFT LOCULATED EMPYEMA” there is no any connection of gastro consultation if any made prior to 10-15 years of the present treatment. While obtaining the policy it was the duty of insurer to have a thorough check up and deny the acceptance of policy but the insurer not done so. The O.P. No.1 has not filed any documentary evidence about the previous ailments.
The Complainant referred the case of Manmohan Nanda Vs. United Indian Assurance Co. Ltd. & another Civil Appeal No. 8386/2015 passed by hon’ble Supreme Court.
“If the insurance company is satisfied about the medical condition of the proposer and on such satisfaction it issues the insurance policy, the insurer can not repudiate the mediclaim alleging pre-existing illness, where such illness is not expressly excluded under the policy from the cover note”. The O.P. no.1 has not applied its mind and repudiated the claim which is illegal. It amounts to deficiency in service on the part of O.P. No.1. The Complainant has a fit case to allow the claim and accordingly, it is ordered:
ORDER
The complaint is allowed on contest against the O.P. No.1 and as banker the O.P. No.2 has no any liability. The O.P. No.1 is directed to reimburse Rs. 4,22,817/- to the Complainant along with compensation of Rs. 50,000/- and litigation expenses of Rs. 10,000/- within one month of this order. In case of non-payment the amount will carry 7% interest P.A. w.e.f. dated discharge i.e. 05.09.2021.
Order pronounced in the open court on 5th day of Feb. 2024.
Supply free copies to the parties.
