This appeal is directed against the judgement and final order passed by the Ld. D.C.D.R.F, Dakshin Dinajpur on 30/08/2018 in connection with CC/45/2018. The fact of the case in nutshell is that the respondent M. Tokder had purchased a Mediclaim policy no. 150703/48/15/8500002645 from Branch Manager National Insurance Company of Balurghat through Bank of India, Balurghat Branch for getting insurance coverage for the purpose of medical treatment of his wife, son and daughter. The period of insurance covers from 17/03/2016 to 16/03/2017. On 21/02/2017 the wife of policy holder Smt. Sathi Tokder become ill and she was admitted in Bhagirathi Neotia woman and child care centre at Kolkata for operation over Fibroid auteurs where she was operated by Dr. K. Ghosh and discharged on 26/02/2017. Thereafter, the policy holder that is the complainant of CC/45/2018 M. Tokder submitted the claim for realization for treatment cost from the insurance company on 21/03/2017 by placing all necessary documents for getting Rs. 1,41,241 as total expenses he has incurred for the treatment of his wife and all relevant medical papers were submitted before the MD India Health Care Service who was the service provider to the said insurance coverage.

            In spite of submitting the claim in proper forum by furnishing all relevant documents the insurance company did not pursue for medical reimbursement as claimed by the complainant in repeated occasions but all his efforts did not bring good results. Further the complainant sent a requesting letter dated 06/04/2018 for settlement of his claim within 15 days but no response was there on the part of the settlement authority. Thereafter, the policy holder that is the complainant submitted the consumer complaint before the Ld. D.C.D.R.F, Dakshin Dinajpur.

            The OP National Insurance Corporation had contested the consumer complaint by submitting the W.V and the quintessence of the averment of Op Insurance Company speaks that as per condition of the said policy, the disease like of Fibroid auteurs for the first 12 months was excluded from the date of inception of the policy. But the wife of the complainant has gone through the treatment within 3-4 months from the date of policy for the disease which was excluded in the exclusion clause of the said policy coverage.  Another averment of the OP no. 1 who also covers the case of OP no. 2 that the complainant did not channelize the claim application in proper method and all necessary documents which he was compelled to furnish before the OP no. 2 could not be furnished there and third averment of the opposite parties in the  case is that the claim of the complainant was not completely repudiated and the formality of repudiation was still pending but by this time, the complainant has raised the consumer complaint which was pre mature one. Ld. Forum after hearing the both sides came to a conclusion that the insurer that the opposite party of this case has failed to provide the terms and conditions of the policy to the complainant at the time of its inception and for that reason the company got no right to repudiate the claim arbitrarily. Ld. Forum based upon of this decision after consulting a judicial decision of Hon’ble National Commission reported in 2014(2) CPR. And asked the insurance company OP no. 1 to pay Rs. 1,41,241 that the claim amount along with interest at the rate of 8 per cent per annum with effect from 18/05/2017 and also litigation cost of Rs. 5,000.

D E C I S I O N S   W I T H   R E A S O N S

            Admitted position is that the respondent is a consumer under the National Insurance Company Ltd. as he has purchased the insurance policy on 17/03/2017 by making the payment of premium amount through Bank of India, Balurghat Branch and the policy coverage period was between 17/03/2016 and 16/03/2017. It is also fact that the wife of the policy holder developed a disorder Fibroid auteur and she was admitted in a reputed nursing home and hospital at Kolkata where the Fibroid auteurs was operated and she was discharged on 26/02/2017 and the policy holder has incurred Rs. 1,41,241 for such treatment. The documents he has furnished in respect of medical expenses has sufficiently established in this case. It is also admitted position that the respondent submitted the claim with all relevant documents before the appellant company on 04/04/2017. But his claim was not entertained on the exclusion ground enumerated in the terms and conditions of the policy and also on the ground that material documents were not provided to the service provider that is OP no. 2 in the complaint case and for that reason the insurance company could not meet the claim though the repudiation was pending for final approval and in the meantime, the consumer complaint has cropped up for adjudication. Ld. Advocate of the appellant at the time of argument mentioned that the claim was not maintainable as because the draft repudiation statement dated 18/05/2018 was still pending for final approval and by this time, the policy holder submitted the consumer complaint and for that reason the consumer complaint should not be entertained as It was registered at a pre mature stage. It was further contended on the part of the Ld. Advocate of the appellant that the treatment of the wife of the complainant was held for a disease called Fibroid Auteurs within one year of the policy which is completely barred as per clause 4.3 in the terms and conditions of the alleged insurance coverage. So, the complainant/respondent has got no relief in this case in the eye of law but through oversight and through mis conception of facts and laws, the Ld. Forum had passed the impugned order which is liable to be set aside. This argument is countered in converse on the part of the respondent that the draft repudiation statement for approval dated 18/05/2018 clearly speaks that the service provider of the insurance company that is MD India Health Service Ltd. has repudiated the claim by issuing this draft repudiation statement and for that reason, the claim of the complainant was frustrated and at last he was compelled to come before the Forum. It is contended further on the part of the respondent that the said terms and conditions of the insurance policy was not provided to the policy holder at the time of issuing the policy certificate and it was beyond the knowledge of the policy holder about the said exclusion clause of one year waiting period and if he had knowledge of the existence of the said exclusion clause in the terms and conditions of the policy then he would have thought twice to purchase the said policy and at this stage while the operation has already held and the complainant has incurred a huge amount, the insurance company should not be absolved from the liability. After hearing valuable argument canvassed before us this Commission find that certainly there was an exclusion clause in the terms and conditions of the said policy and for that reason the insurance company has sufficient ground to repudiate the claim of the complainant but on the other hand it has not been proved on the part of the appellant company that the said terms and conditions were well informed to the policy purchaser at the time of purchase through Bank of India. So, bona fidy is there on the part of the complainant/respondent. And Ld. Forum at the time of adjudication has rightly held that the insurance insurer who failed to provide terms and conditions of policy to the complainant has no right to repudiate the claim arbitrarily. And this piece of adjudication on the part of the Ld. Forum is acceptable in the eye of law and this Commission finds no infirmity in the order of the Ld. Forum.

            The fact remains that the repudiation of claim has not yet come to its finality and on the basis of draft repudiation, it was pending for approval. The complainant has come before the Fora with a consumer complaint in a pre-mature stage though it has rightly accepted by the Ld. Forum on the humanitarian ground but the interest imposed at the rate of 8 percent p.a. over the awarded money Rs. 1,41,241 since the date of draft repudiation dated 18/05/2017 has no justification. In this case, the complainant is a renowned lawyer and perhaps he had no financial burden to bear the litigation cost as he is in a legal profession. So, the litigation cost awarded in favour of the complainant not to be justified one. Thus, the appeal is hereby disposed of in the following way: -

Ordered,

            That the appeal be and same is partly allowed on contest without any cost. The order of Ld. Forum asking the OP no. 1 that is National Insurance Co. Ltd. to pay Rs. 1,41,241 within 30 days is hereby confirmed but the interest at the rate of 8 per cent per annum with effect from 18/05/2017 up to the date of the final order of Ld. Forum is hereby rescinded. Now, the Op no. 1 that is the appellant of this case is hereby asked to pay Rs. 1,41,241 to the respondent M. Tokder within 30 days either by account payee cheque or draft or by cash from the date of receiving the copy of this order of appeal which to be supplied free of cost to the parties, failing which an interest at the rate of 9 per cent per annum will be accrued there on till the final payment.

            The order of Ld. Forum to pay the litigation cost of Rs. 5,000 is hereby set aside. Let a copy of this order to the parties free of cost and let a copy be communicated to the Ld. D.C.D.R.F, Dakshin Dinajpur through e-mail.