BANSHI RAM MODI vs NEW INDIA ASSURANCE CO.

THIS is a complaint filed by the complainant against the Divisional Manager, New India Assurance Company, Divisional Office, Nagmatia Road, Gaya. It has been alleged that the complainant had taken a Mediclaim Insurance Policy, bearing No. 4854060402847 which was valid from 23.10.90 to 22.10.91. The complainant had a heart problem detected on 19.5.91 and got Coronary Artery Bypass Surgery done at B.M. Birla Heart Research Centre, Calcutta. On completion of the treatment a claim for Rs. 1,42,993.00 was filed with the O.P. on 20.1.92 but the O.P. did not entertain the claim and hence the complaint has been filed before us. In the written statement filed by the O.P., it has been pointed out that the Bypass Surgery was done after the expiry of the Policy period i.e. on 13.11.91 (the Policy expired on 22.10.91). It has also been averred in the written statement that the complainant was suffering from diabetes for the last ten years which fact he did not disclose at the time of taking the Policy and therefore has violated the terms and conditions of the Insurance Policy. The averment in the written statement has been made by the O.P. on affidavit. On the written statement of the opposite party the complainant has also filed a rejoinder on a duly sworn affidavit, wherein it is asserted that at the time of taking the Policy there was no heart ailment from which the complainant was suffering. It was for the first time on 19.5.91 that the complainant knew about his ailment through a medical check-up and he was referred to the B.M. Birla Research Centre, Calcutta. On 22.7.91 he was checked up at the Birla Heart Research Centre. On 19.9.91 the complainant informed O.P. that he has been advised open heart surgery for which he had been admitted at the Birla Heart Research Centre. He had already deposited Rs. 1,03,300/- (One lac three thousand and three hundred) only as advance charges of the Hospital. He was duly admitted on 23.9,91 and on 24.9.91 the complainant had another heart attack at the hospital and the operation due to be done was cancelled. He was thereafter admitted on 10.11.91 for admission. The operation was successfully performed on 11.11.91. On 18th January, 92 the complainant filed a claim with the O.P. for reimbursement of expenses incurred in his treatment.

WE have perused the documents produced by the complainant and heard the learned Advocates for both the parties. WE fail to appreciate the contention of the O.P. that the complainant concealed the history of diabetes for the last ten years and thereby failed to disclose material information with regard to the heart ailment with which he suffered. It is not at all necessary that every diabetic patient will have heart attack. Moreover, in this case the diabetes did not appear to be severe because the previous history as mentioned in the prescription of the B.M. Birla Heart Research Centre shows that his diabetes was controlled by diet control. There is, however, substance in the contention that the operation expenses were incurred after the expiry of the Policy even though an advance was deposited earlier and therefore these expenses for the operation were incurred after the expiry of the Policy can not be said to be reimbursable under the terms of the Mediclaim Policy. There is however no jurisdiction for not reimbursing the expenses during the period the Policy was in force that is for Angiography etc. due at the Birla Heart Research Centre, Calcutta as an indoor patient during the period when the policy. There is also no justification either for not reimbursing the medical practitioner''s consultation fees during the period the policy was in force, for which due receipts were obtained and filed with the claim. What is relevant for consideration is that even though the claim was filed on 20.1.92 there has been no repudiation of the claim or settlement of the claim either in full or in part. This fact of non-decision of the claim filed by the complainant before the O.P. can not but be characterised as a deficiency in service on the part of the O.P. due to their negligence. The complainant is therefore liable to be compensated.

As for the total expenses incurred and claimed by the complainant a sum of Rs. 1,42,993/- has been spent in the treatment of the complainant. Out of this sum a sum of Rs. 1,05,550.00 was incurred when the Insurance Policy had expired. The remaining expenses of Rs. 37,443.00 were incurred when the Policy was in force and in the written, version filed the Insurance Company while they have not given any reason for not paying those expenses except by saying that the complainant concealed the fact of his diabetes were which he was suffering for the last ten years. We have already discussed this contention of the O.P. There can be no justification for not reimbursing expenses incurred by the complainant in the treatment of a problem which can not be direct related to diabetes.

CONSIDERING all these facts viz. the expenses of Rs. 37,443.00 incurred in course of the treatment of his heart ailment when the Policy was in force and the mental agony and anxiety suffered by the complainant on account of the opposite party not paying his due claim nor repudiating it the complainant is allowed a compensation of Rs. 50,000/- to be paid by the O.P. We further allow a sum of Rs. 2,000/- as costs of litigation. Complaint allowed.