Hon’ble Mr. Haradhan Mukhopadhyay, President.
The basic fact of the complaint case is that the Complainant Pampa Barman is a doctor and wife of Dr. Indrajit Kumar Nath. The husband of the Complainant Dr. Indrajit Kumar Nath took up mediclaim insurance policy from the OP Company Oriental Insurance Company Limited vide Policy number 313202/48/2017/14 issuing office Cooch Behar branch to pay hospitalization expenses as per terms of the policy. The Complainant paid yearly Premium for Rs. 9,831/- duly received by the OP Company in the year 2010 for the family members of the Complainant constituting of four persons, the Complainant, her husband and their two daughters namely Sampriti Nath and Ipsita Nath. Subsequently the said policy was upgraded to sum of Rs. 3,00,000/- from the initial policy of Rs. 1,00,000/-. Accordingly an increased premium was also paid for Rs. 13,251/- to the OP time to time for renewal under the new policy name which was renamed as “Happy Family Floater-2015” policy with Policy number 313202/48/2020/15 Rs. 3,00,000/- valid for the period 10/04/2019 to midnight 09/04/2020 for the aforesaid four persons. During the subsistence of the said policy Dr. Indrajit Kumar Nath, the husband of the Complainant suddenly fell serious ill and was medically treated at P.K. Saha Hospital where from as per advice of the doctor he was taken to Siliguri and admitted to Dr Malay’s Hospital and Neuroscience Center, Siliguri. Dr. Nath was medically treated for the period 16.02.2020 to 11.03.2020. The total expense for such treatment was Rs. 7,74,800/-. Dr. Indrajit Nath was in unconscious state since February, 2022. So, the Complainant filed this case as his wife. The Complainant informed to the OP-1 the BM, Oriental Insurance Company Ltd., Cooch Behar about such treatment claiming reimbursement of medical expenditure for the treatment of Indrajit Nath along with all documents vide Claim No. 313203/48/2020/045. Despite submission of all documents as per demand of the Complainant the OP-1 & 2 M/S Oriental Insurance Company Ltd. and its M.D. settled the claim for Rs. 90,000/- against the claim of Rs. 3,00,000/-. OP with malafide intention, did not allow the full claim of Rs. 3,00,000/- raised by the Complainant which is unfair trade practice. Having found no alternative, the Complainant served legal notice upon OP-1 & 2 through her advocate Kumardip Mukherjee which the OP duly received but did not allow the claim of the Complainant. The cause of action for the present case arose on and from 2015 and is still continuing till the filing of the case. The Complainant claimed for an award for Rs.3,00,000/- for actual medical claim, Rs. 1,00,000/- for mental pain and agony and Rs. 50,000/- for unfair trade practices and Rs. 20,000/- for litigation cost.
The OP contested the case by filing written version wherein they denied each and every allegation of the Complainant. The OP challenged the case on the ground that the Complainant is not a consumer and the present case is not maintainable. The positive defence case of the OP in brief is that the OP issued a silver plan (Happy Family Floater Policy-2015) mediclaim insurance policy for the Complainant and her family members bearing number 313202/48/2020/15 for the period 10.04.2019 to 09.04.2020 and sum insured is Rs.3,00,000/- with a condition precedent that the expense for treatment if contracted after inception of the first policy (subject to continuity being maintained) are not payable during the waiting period. In the instant case, the ailment was diabetes disease for which the waiting period is 2 years. Sum insured for Rs. 3,00,000/- is not completed 2 years. This policy number for last 2 years where Rs. 3,00,000/- valid from 10.04.2018 to 09.04.2019 and another for Rs. 1,00,000/- valid from 10.04.2017 to 09.04.2018. It is clear that the waiting period of 2 years for sum insured Rs. 3,00,000/- has not completed the waiting period of 2 years up to the date of the falling ill of the insured. So the claim was settled taking into consideration of sum insured Rs. 1,00,000/- valid from 10.04.2017 to 09.04.2018. Policy sum insured enhanced commenced from 10.04.2018 but the Complainant's husband fell ill on 15.02.2020 which is less than the waiting period of 2 years. The OP Company calculated the claim for Rs. 90,000/- which was approved by the Branch Manager. Accordingly, a discharge voucher was issued and sent to the Complainant on 09.10.2020. But the Complainant did not return back. The calculation of mediclaim was prepared as per Clause 4.3 of IRDAI guidelines. The Complainant is a valuable customer of the OP Company for a long time. The present complaint is liable to be dismissed with cost.
The respective pleadings of the parties and the different factual and legal disputes involved in this case led this Commission to set up the following points for proper adjudication of the case.
POINTS FOR DETERMINATION
- Whether the Complainant is a Consumer or not?
- Whether the Complainant is entitled to get relief as paid for?
- To what other relief if any the complaint is entitle to get?
DECISION WITH REASONS
Point No.1.
The OPs challenged the status of the complaint on the ground that the Complainant is not a Consumer under the CP Act and the present case is not maintainable.
Although no specific argument is advanced by the Ld. advocate for the OP yet after perusing the pleadings of the parties and the evidence on case record it transpires that it is the admitted position that the Complainant purchased one insurance policy from the OP which was subsequently upgraded from Rs. 1,00,000/- to Rs. 3,00,000/-.
There may have dispute regarding the claim of the Complainant but the relation between the parties is well within the perview of the CP Act and the amount of claim raised by the Complainant is also within the pecuniary jurisdiction of this Commission.
Accordingly the present case is maintainable subject to the fate of the Points number 2 and 3 which are to be decided herein after. Accordingly Point number 1 is answered in favour of the Complainant.
Point No.2 & 3.
These two points relate to entitlement of relief by the Complainant. It is the admitted position that the Complainant purchased a silver plan "Happy Family Floater" mediclaim insurance policy bearing number 313202/48/2020/15.
The Complainant also proved some documents in the form of different annexures. The said documents relating to insurance in the name of the Complainant, her husband and two daughters are well established. There is no dispute that the said initial Policy was upgraded for Rs. 3,00,000/-.
The OP Company challenged the entitlement of the claim that it is a condition precedent that the expenses for treatment if contracted after Inception of first policy subject to continuity being maintained are not payable during the waiting period.
The OP Company challenged that, in the instant case, the ailment was diabetes disease for which waiting period is 2 years.
It is found from the case record that the husband of the Complainant fell ill on 15.02.2020. The OP denied the claim of the Complainant on the ground that it is less than the waiting period of 2 years.
Ld. Advocate for the Complainant argued that it is not a new insurance policy. Actually the Policy was purchased in 2015. The said Policy was continued on payment of regular premium of Rs. 9,831/- till the date of upgradation of the original policy.
After perusing all the documents, it is evident that the claimant Mr. Indrajit Nath was actually medically treated. There is no denial that the amount spent for medical expenses was not actually incurred. But the point of dispute by the OP Company is nullified by both oral and documentary evidence.
The defence counsel relied on Clause 4.3 of the policy terms and conditions under “Happy Family Floater Policy 2015”. It is fact that as per Clause 4.3, the waiting period for diabetes disease in order to raise claim is 2 years.
Ld. advocate for the Complainant rightly argued that the said limitation should actually be counted from the date of the original policy because it is not a new policy but the original Policy was top up by upgradation from Rs. 1,00,000/- to Rs. 3,00,000/-. As per annexure-5, clause 6.6, increase in sum insured under the policy may be considered by the company only at the time of renewal. As per clause 6.6 (iii) if there are no claims reported in the two immediate preceding policy periods, change to the next plan (silver to gold or Gold to Diamond) at the initial S.I. slab or two steps higher from the current S.I., whichever is more, is allowed.
Thus Clause 6.6 clearly goes in favour of the Complainant on the ground that In Para 10 of the written version, OP categorically stated that the “Happy Family Floater Policy 2015” mediclaim insurance policy was a silver plan.
Ld. defence counsel further argued that since the waiting period was less than 2 years in the instant case so the previous policy has to be followed.
The argument is not acceptable because the Complainant just did top up by payment of extra premium by upgrading from Rs. 1,00,000/- to Rs. 3,00,000/-. Top up is not a new policy, it was just continuation of the previous one.
The OPs could not prove any document on the ground that the upgradation of the old policy should be treated as new policy. Annexure 1 to 5 clearly supports the claim of the Complainant by virtue of which under no stretch of imagination the claim of the Complainant can be considered as a new policy, it is just continuation of old policy.
In the backdrop of the assessment of the evidence and observations made herein above, the Commission comes to the finding that the Complainant successfully proved her claim of Rs. 3,00,000/-.
The denial of the claim by the OPs tantamounts to deficiency in service.
Points 2 and 3 are accordingly answered in favour of the Complainant.
Consequently, the complaint case succeeds on contest with cost.
Hence, it is
Ordered
That the CC case No. CC/48/2020 be and same is allowed on contest with cost of Rs.10,000/-. The Complainant do get an award for a sum of Rs.3,00,000/- from the OP-1 & 2 towards actual claim, Rs.20,000/- towards unfair trade practice and mental pain and agony & Rs.10,000/- towards litigation cost. The OPs are directed to pay Rs.3,30,000/- to the Complainant within 30 (thirty) days from the date of the passing the order failing which the Complainant shall be entitled to get an interest @ 6% p.a. on the awarded money from the date of passing the final order till the date of realisation.
DA to note in the Trial Register.
Let a plain copy of this order be supplied to the parties concerned by hand/by post forthwith, free of cost for information and necessary action, if any.
The copy of the Final Order is also available in the official Website www.confonet.nic.in.
Dictated and corrected by me.
