Date of filing:-25/02/2020.
Date of Order/Judgement:-16/01/2023.
DISTRICT CONSUMER DIPUTES REDRESSAL COMMISSION
B A R G A R H
CONSUMER COMPLAINT NO. 26 OF 2020
Prasanta Sharma, S/o. Gopal Sharma, aged about 34 years, Occupation. Business, R/o. Old N.H. 6, Bhatli Chowk, Saraswati Enclave, Bargarh, Po/Ps/Dist. Bargarh.
..... Complainant.
-: V e r s u s :-
(1) Branch Manager, Andhra Bank, Bargarh Branch, Bargarh, At. Hospital Road, Bargarh,
Po/Ps/Tahasil, Dist. Bargarh
(2) The General Manager, Cigna TTK Health Insurance Company Limited, 401/402,
Raheja Titanium, Western Epress High Way, Goregaon East, Mumbai 400063.
Opposite Parties.
Counsel for the Parties:-
For the Complainant: - :- Sri M.K. Satapathy with Associates.
For the Opposite Party No.1:- :- Exparte.
For the Opposite Party No.2:- :- P.K. Mahapatra.
-: P R E S E N T :-
Smt. Jigeesha Mishra ..... ..... ..... ..... ..... P r e s i d e n t.
Smt. Anju Agarwal ..... ..... ..... ..... ..... M e m b e r (W).
Dt.16/01/2023. -: J U D G E M E N T:-
Presented by Smt. Jigeesha Mishra, President :-
- The Case of the Complainant is that the Complainant Prasanta Sharma is a bonafide Consumer of the Health Insurance policy of the Opposite Parties done vide policy no. 100200000001/01/00 valid from Dt. 19/04/2018, for the Policy the Complainant has also been paying the requisite premium thereof regularly. He was also assigned insurance certificate No. 100100004347/01/00 by the Opposite Parties.
The Complainant or the Insurance holder was a healthy and hearty person during the drawing of the policy so also thereafter. The policy was also drawn after due medical check up by the Opposite parties authorized medical testing centre Bargarh. The Complainant has suffered with sudden heart attach and treated in Narayan Instiuture of cardac science Narayan Hrudayalaya Limited, Bangalore. Wherein even acrotic valve operation was conducted on the Complainant. The Complainant being a policy holder is entitled for the insurance claim as the insurance policy of the Complainant has placed the insurance claim before the Opposite Parties. The Complainant has also furnished relevant documents as desired by the Opposite Parties time to time on their direction. Instead of settling the claim of the Complainant, the Opposite Parties have deferred the matter on different plea. Finally they have denied to settle the claim on the ground that the Life Assured has suppressed information and he was having smoking addition at that time. They have also been requested for reexamination of the matter by the Complainant but no result. The Opposite Parties have not paid insurance claim to the Complainant. Finding no way the Complainant has caused service of pleader notice dt. 13/01/2020 on the Opposite parties calling upon them to release the insurance claim amount. The Opposite Parties received the notice but remained silent.
Such acts of the Opposite parties amounts to deficiency in service.
- The Opposite Party No.1 did not file its version and set exparte.
- Opposite Party No.2 Cigna TTK Health Insurance Company filed its version and admitted that the insurance policy was issued by the insurance Company after getting proposal of the Complainant through the Opposite Party No.1 bank under master policy No. 10020000001/01/00 in the name of master policy Holder Andhra Bank on receipt of proposal the insured/Complainant through Andhra Bank, Family floater Policy bearing certificate no. 110100004347/01/00 has been issued under the said master Policy for the sum assured amount of Rs. 5,00,000/-(Rupees five lakh) only in respect of the Complainant and his family members namely Sobha Sharma (Spouse), Dibya Shankar Sharma and Prathistha Sharma, the son and daughter respectively and the said policy was valid with effect from Dt. 19/04/2017. The Opposite Party submitted that during currency of the policy on Dt. 08/08/2019 the Complainant was admitted at Narayan Institute of Cardiac Science, Bangalore and got discharged on 20/08/2019. He was diagnosed with severe Aortic Stenosis, Sinus Rhythm which requiresurgery and he has requested the TPA through the hospital concern to issue authorization for cashless service towards the expenses for an estimated amount of Rs. 5,69,600/-(Rupees five lakh sixty nine thousand six hundred) only. The Opposite party on scrutiny of the documents submitted by the insured/Complainant, could noticed from the clinical history and the diagnosis that the patient had been suffering from hypertension (HTN) since two years of his admission in the hospital. The Opposite Party requested the complainant several times vide its letter Dt. 11/11/2019, Dt. 22/11/2019, Dt. 03/12/2019 and 14/12/2019 but did not receive any response from the side of the Complainant. The Complainant did not provide any information regarding hypertension. Hence the Opposite party repudiated the claim of the Complainant and informed the same to the Complainant vide letter Dt. 19/01/2020.
There is no deficiency on the part of the Opposite party.
- Perused the document filed by the Complainant and Opposite party and following issues are framed :-
- Whether the Complainant is a Consumer of the Opposite Parties ?
- Whether the Opposite Parties are deficient in their service ?
- What relief the Complainant is entitled to get ?
Issue No.1.
The Complainant Prasanta Sharma had paid Rs.8312/-( Rupees eight thousand three hundred twelve) only for the period from 19/04/2018 to 18/04/2019 towards premium for health insurance policy. Accordingly the Complainant is a Consumer of the Opposite Party insurance Company.
Issue No.2.
The Opposite party in its version submitted that the Opposite party several times requested vide letter Dt. 11/11/2019, Dt. 22/11/2019, Dt. 03/12/2019 and Dt. 14/12/2019 to provide additional information i.e. his first Consultation paper, prescription for hypertension (HTN) but the Complainant did not respond. Perused the documents filed by the parties and it reveals that on Dt. 18/11/2019 the Complainant Complied the request of the letter dated 11/11/2019 of the Opposite party and all the required documents including first Consultation report. But the Opposite Party without settling the claim of the Complainant taking plea. Non settlement of claim is amounts to deficiency in service on the part of the insurance company.
Issue No.3.
The Complainant submitted the bill of hospital charges for Rs. 6,43,876.28/-(Rupees six lakh fourty three thousand eight hundred seventy six and twenty eight paise) only. The policy is insured for Rs. 5,00,000/-(Rupees five lakh) only. For deficiency in service of the Opposite Party the Complainant is entitled for the sum insured. Accordingly the following order is made :-
O R D E R
The Complaint is allowed on contest against Opposite Party No.2. The Opposite Party No.2 is directed to pay Rs. 5,00,000/-(Rupees five lakh) only to the Complainant withy67in one month from the date of this order. Failing which the amount will carry 12% interest P.A. till realization. Further Opposite party No.2 is directed to pay Rs. 2,00,000/-(Rupees two lakh) only Compensation for harassment and mental agony and Rs. 20,000/-(Rupees twenty thousand) only for litigation expences.
Order pronounced in open court on this 16th day of January 2023.
Supply free copies to the parties.
Typed to my dictation
and corrected by me.
I agree/-
( Smt. Anju Agrawal) (Jigeesha Mishra)
Dt.16/01/2023 Dt.16/01/2023
M e m b e r (w) P r e s i d e n t
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