TRIPTI MUSTAFI Vs. NEW INDIA ASSURANCE CO LTD

JUDGEMENT

(1.) This an appeal directed against the Judgment and Orders passed by the learned District Forum CDF-I in Case No. 181 of 2002 on 31.5.2004 dismissing the complaint on contest without any cost.

(2.) The facts of the case, in brief, are that the complainant Mrs. Tripti Mustaphi had taken a Mediclaim Insurance Policy from New India Assurance Co. Ltd. 4, Mango Lane, Kolkata on 2.5.1999 for one year to cover her medical expenses. The policy expired on 1.5.2000. The complainant again renewed the policy on 10.7.2000 for another year and thus there was a break of nearly 2 months between the two policies in their continuity. In the month of Oct., 2000 the complainant developed obstructive jaundice which was diagnosed by Dr. Sabyasachi Pattanayak and upon his advice the complainant had undergone an ultrasonography test on 22.10.2000, which showed that the complainant had stone in the Commmon Bile Duct ERCP. The stone was extracted by Dr. Pattanayak in Kothari Medical Centre, Kolkata on 28.11.2000, and she was hospitalized there till 2.12.2000. The complainant had raised a claim for reimbursement of medical expenses amounting to Rs. 19,704.65 on the O.P. Nos. 1 and 2 through O.P. No. 3. On 15.3.2001 the complainant received a communication from the O.P. No. 2 intimating that her claim for reimbursement had been repudiated by O.P. Nos. 1 and 2 on the ground that she had a pre-existing disease which made her claim invalid in law. On receiving the intimation the complainant had written to O.P. No. 1 on 18.4.2001 to know as to how the fact of pre-existence of the disease was ascertained and established by them. From the facts placed before the learned Forum it appeared that in the month of July 1997, i.e., much before the policy was purchased by the complainant she had to undergo a surgery to extract gall bladder by Dr. Mrinmoy Nandi stated to be an eminent surgeon. One year after the said operation Dr. Nandi had done another operation on the complainant for removal of her appendix.

(3.) The O.Ps. 1 and 2 had obtained the opinion of the panelled doctor Dr. A.K. Podder who had opined that the present case of jaundice coupled with existence of stone in the Common Bile Duct was a pre-existing disease and the O.Ps. 1 and 2, i.e., respondent Nos. 1 and 2 had repudiated the claim on the basis of such medical opinion. The complainant had approached Kreta Suraksha Samity and took up the matter with them. The secretary of the said Kreta Suraksha Samity had obtained opinion from the doctor Mr. Mrinmoy Nandi who had operated the appellant twice as to whether the latest case of stone in the Common Bile Duct of the appellant was a pre-existing one or not. Dr. Nandi has given his categorical opinion dismissing the theory of pre-existence and opined that the existence of stone in the Common Bile Duct had no relation with the earlier operations. The learned Forum after going through the complaint and the written objection filed by the O.Ps. and after hearing both sides came to the conclusion that the stand taken by the respondent Nos. 1 and 2 that due to break of more than 2 months in taking up the second policy the contention of the O.Ps. that the complainant had developed the disease in the meantime which she suppressed while taking up the second policy, could not be dismissed altogether. The Forum had also observed that the complainant had failed to adduce any documentary evidence or to present Dr. Pattanayak who had operated her stone in Common Bile Duct before the learned Forum, which she should have done to reinforce her contention that the latest operation was not due to any pre-existing disease. Even opinion of Dr. S. Pattanayak who had operated the complainant had been placed before the learned Forum for reasons best known to the appellant. The Forum felt that though Dr. Nandi was an eminent surgeon, his opinion was based on distant experience and not associated with the latest operation of the complainant, and, therefore, his opinion was of little relevance in the present case. The Forum relied more on the opinion of the panelled doctor of the O.P. Dr. A.K. Poddar. The Forum, therefore, decided that in view of the above facts the complainant was not entitled to any relief whatsoever in regard to the claim for reimbursement of medical cost from the O.P./respondent Company.