DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: WEST TRIPURA : AGARTALA
CASE NO: CC- 94 of 2023
1. Sri Ganesh Chandra Banik,
S/O- Sri Sunil Chandra Banik,
North Badharghat, Banik Para,
P.O. A.D. Nagar, Agartala,
District- West Tripura,
Pin- 799003.
2. Sri Gourab Banik,
S/O- Sri Ganesh Chandra Banik,
North Badharghat, Banik Para,
P.O. A.D. Nagar, Agartala,
District- West Tripura. ….............Complainants.
-VERSUS-
1. The Managing Director,
Bajaj Alliance General Insurance Co. Ltd.,
GE Plaza, Airport Road, Opp. Gunjan Talkies, Pune,
Maharastra, Pin- 411006.
2. The Branch Manager,
Bajaj Alliance General Insurance Co. Ltd.,
Unit No. 414, 3rd Floor, Aitorma,
Agartala Sentrum, Shakuntala Road,
West Tripura, Agartala- 799001. .......Opposite Parties.
-:PRESENT :-
SRI GOUTAM DEBNATH
PRESIDENT,
DISTRICT CONSUMER
DISPUTES REDRESSAL COMMISSION,
WEST TRIPURA, AGARTALA.
SRI SAMIR GUPTA
MEMBER,
DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION,
WEST TRIPURA, AGARTALA.
C O U N S E L
For the Complainant : Sri P.R. Barman,
Sri Koushik Nath,
Sri Pranjit Nag,
Sri Dipjyoti Paul,
Learned Advocates.
For the O.Ps : Sri Subhajit Chakraborty,
Smt. Baisakhi Chakraborty,
Learned Advocates.
ORDER DELIVERED ON: 2024.
F I N A L O R D E R
1. This case is filed by Ganesh Chandra Banik and Gourab Banik here-in-after called the “Complainants” against the Managing Director, Bajaj Alliance General Insurance Co. Ltd. Pune, Maharastra, here-in-after called the “O.P. No.1” and the Branch Manager, Bajaj Alliance General Insurance Co. Ltd. Agartala, West Tripura, here-in-after called “the O.P. No.2” alleging deficiency in service on the part of the O.Ps.
1.1 The case is short is that the complainant is the holder of Bajaj Alliance Mediclaim Insurance Policy with the O.P. vide policy No-OG-23-2001-8403-00000162; valid from 01.11.2022 to 31.10.2023.
1.2 That the complainant no. 1 was ill and needed medical care therefore complainant no .2 took the complainant no.1 to the Apollo Multispeciality Hospitals, Kolkata for undergoing treatment.
1.3 On 02.08.2023 cashless facility authorization was passed in favour of the complainants vide claim no- OC-24-1002-8403-00102574 for an amount of Rs.1,00,000/- which was valid upto 17.08.2023.
1.4 After treatment the complainant no.1 got discharged from the hospital on 09.08.2023 and claimed Rs.1,00,000/- which was denied by the O.Ps on the ground that it was erroneously registered and the authorization letter stand null and void under General Denial Clause 20. Till date the complainants have not received any amount of the insurance policy.
1.5 Hence, this case.
2. The O.P. appeared and filed written objection denying the allegations of the complainants made in their complaint petition.
2.1 The O.P. in their written version stated that the complainant had taken a Group Mediclaim(floater) Policy bearing No. OG-23-2001-8403-00000162 having validity from 1st November, 2022 upto 31st October, 2023 which was issued subject to terms and conditions.
2.2 The facts as to the ailments of the complainant as revealed from the medical documents was found to have history of hoarseness of voice insidious in onset gradually progressing in nature and had complaint of LEUKOPLAKIA LARYNX i.e., Right Vocal Chord Keratotic Patch for which he was admitted in the hospital to undergo surgery of Type 1 Laser Cordectomy under General Anaesthesia.
2.3 As the complainants claim falls under policy exclusion clause i.e., General clause 20 it has became outside the scope and consideration.
2.4 II General Exclusion as follows:-
“ 20. External medical equipment of any kind used at home as post Hospitalization care including cost of instrument used in the treatment of Sleep Apnoea Syndrome(C.P.A.P.) continuous Peritoneal Ambulatory Dialysis(C.P.A.D) and oxygen concentrator for Bronchial Asthmatic condition.”
2.5 It is stated that there is no deficiency in service on the part of the O.Ps and hence prayed for dismissal of the complaint.
3. Both the parties submitted evidence on affidavit along with documents.
3.1 Complainant submitted documents namely Insurance Policy, Medical Bills, Rejection Letter dated 09.08.2023, Legal Notice dated 26.08.2023.
3. Hearing argument the following point is taken up for discussion and decision:-
(I) Whether the complainant suppressed material fact in the proposal form at the time of taking the Insurance Policy?
DECISION AND REASONS FOR DECISION:-
4. The Discharge Summary of Apollo Hospital shows that the complainant was admitted in Hospital on 7th August, 2023 and was released on 9th August 2023. The diagnosis was “Right Vocal Chord Keratotic Patch.” Surgery was done for “Type 1 Laser Chordectomy under General Anaesthesia.” The patient was admitted in hospital with history of Hoarseness of voice insidious in onset gradually progressive in nature. Therefore, Keratotic Patch like a mole which was Type 1 in nature which signifies that at the time of taking the policy of Insurance in the month of November, 2022 the patient had no reason to understand that he had any type of disease and suppressing such disease he obtained the policy of Insurance because after 10 months the complainant/patient suffered from hoarseness of voice. Therefore, the denial of claim by the O.P. Insurance Company under General Exclusion Clause is unjustified. As such tantamounts to deficiency in service.
5. The point is decided accordingly.
6. In the result, the O.P. Insurance Company is directed to pay the amount of Rs. 1 lakh to the complainant with interest @ Rs.7.5% P.A. from the date of filing of this case i.e., 17.10.2023 with further compensation of Rs.25,000/- inclusive of litigation cost.
7. The case stands disposed of.
8. Supply copy of this order free of cost to the parties.
Announced.
SRI GOUTAM DEBNATH
PRESIDENT,
DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION,
WEST TRIPURA, AGARTALA
SRI SAMIR GUPTA
MEMBER,
DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION,
WEST TRIPURA,AGARTALA.
