Date of filing:- 10/02/2020.

Date of Order:-04/03/2024.

DISTRICT CONSUMER DISPUTE REDRESSAL COMMISSION

B A R G A R H (ODISHA).

Consumer Complaint No. 16 of  2020.

            Sri Gokulananda Swain, aged about 53 (fifty three) years, Son of Late Gouri Shankar Swain, Resident of Shyama Chowk, Ward No. 01, Barpali, Ps/Po. Barpali, Dist. Bargarh(Odisha).                   

                                                                                    .....       ....     .....           Complainant.

-: V e r s u s :-

1. Branch Manager, Andhra Bank, Barplai Branch, Ps/Po/Tahasil. Barpali, Dist. Bargarh, Odisha.
2. United India Insurance Co- Ltd through Divisional Manager, At- 1^st Floor, Shivlok Complex, Gaiety Talkies Road, Po/Ps/Dist. Sambalpur-768001.
3. Heritage Health Insurance Tpa Pvt. Ltd., Nicco House, 5^th Floor, 2 Hare Street, Kolkata-700001                

                                                .....       .....       .....   Opposite Parties.

Counsel for the Parties:-

For the Complainant :-            Sri T.C.Tripathy, Advocate with associates.

For the Opposite Party No.1(one) :-    Ex-parte.

For the Opposite Party No.2(two) :-    Sri A.K.Dash, Advocate with associates.

For the Opposite Party No.3(three) :-Ex-parte.

                                                            -: P  R  E  S  E  N  T :-

Smt. Jigeesha Mishra               .....       .....       .....       .....       .....       P r e s i d e n t.

Smt. Anju Agrawal             .....            .....       .....       .....       .....       M e m b e r (W).

Dt.04/03/2024.                                 -: J   U  D   G  E  M  E  N  T:-

Presented by Smt. Anju Agrawal, Member(w):-   

1)         The case of the Complainant is that the Complainant has taken an insurance Policy namely Andhra Bank Arogyadaan Group Health Insurance Policy of Opposite Party No.2(two) and paid premium through Opposite Party No.1(one), the Opposite Party No.3(three) is one of the service providers of the company i.e. Third Party Administrator. The Complainant had paid premium of Rs. 28,615/-(Rupees twenty eight thousand six hundred fifteen)only and the Complainant has been issued with insurance policy No. 0504002819P103945442 valid from 9^th day of June 2019 to 8^th day of June 2020. The aforesaid policy covered his wife Deepanjali Swain, son namely Abhinab Kumar Swain. During the validity period of the policy the wife of the Complainant complained about severe pain in her knee for which the Complainant's wife got admitted on 23^rd of November 2019 at Ashwin Hospital Cuttack. The Complainant's wife left knee was replaced and accordingly after treatment discharged on 30^th day of November 2019. For the treatment in the hospital, the hospital charged Rs. 2,65,330/-(Rupees two lakh sixty five thousand three hundred thirty)only and issued bill for the same, the Complainant lodged claim for reimbursement of the total expenses but surprisingly the Opposite Party No.2(two) through the Opposite Party No.3(three) have paid Rs. 80,000/-(Rupees eighty thousand)only and the Complainant  has to pay the rest amount of the bill i.e. Rs. 1,85,000/-(Rupees one lakh eighty five thousand)only to the hospital. The Complainant after discharge of his wife requested the Opposite Parties vide mail 5^th day of December 2019, but none of the Opposite Parties have responded to settle the claim of the Complainant. For the unfair trade practices as well as deficiency in service caused by the Opposite Parties, the Complainant filed this complaint before this Commission praying that the Opposite Parties be held jointly and severally liable to pay Rs.2,50,000/-(Rupees two lakh fifty thousand)only to the Complainant along with pendent elite and future interest.

2)         The case of the Opposite Party No.1(one) (Bank is that the Opposite Party No.1) did not appear before this Commission. Here Opposite Party No.1(one) is set ex-parte.

3)         The case of the Opposite Party No.2(two) has filed its version and submitted that the Complainant is the account holder of Opposite Party No.1(one) and on payments of Rs. 2,884/-(Rupees two thousand eight hundred eighty four)only towards premium including taxes through Opposite Party No.1(one) is covered under the Arogyadaan Group Health Insurance Policy bearing No. 0504002819P103945442 having validity from 09-06-2019 to 08-06-2020 issued in favour of M/s Andhra Bank covering the risk of the Complainant along with his family for a sum insured of Rs. 1,00,000/-(Rupees one lakh)only subject to certain terms and conditions. On dt.23-11-2019, Ashwini Hospital Cuttack intimated the Opposite Parties regarding the admission of wife of Complainant and accordingly after scrutinizing the claim papers the claim was admitted for Rs. 80,000/-(Rupees eighty thousand)only and approval letter was sent to the hospital authority on 29-11-2019 and also to intimate if any balance amount is there within the limit of the insured amount.

            As the Complainant is entitled to reimburse up to Rs. 1,00,000/-(Rupees one lakh)only as per the sum insured the Opposite Party has already paid Rs. 80,000/-(Rupees eighty)only to the hospital authority and the Complainant has not intimated the rest amount the Opposite Party is no way liable for any compensation, there lies no deficiency in service on the part of the Opposite Party.

4)         The case of the Opposite Party No.3(three) is that the Opposite Party No.3(three) has not appeared before this Commission, hence set ex-parte.

5)         Perused the documents filed by the Parties and following issues are framed:-

Issues

1. Whether the Opposite Parties are deficient in their service ?
2. What relief the Complainant is entitled for ?         

Issue No.1(one)

6)         The Complainant had obtained Andhra Bank Arogyadaan Group Health Insurance Policy vide Policy bearing No. 0504002819P103945442 and the said policy was renewed on dt. 10-06-2019 and accordingly the Complainant paid Rs. 28,615/-(Rupees twenty eighty thousand six hundred fifteen)only towards premium, the sum insured of the said policy being Rs. 10,00,000/-(Rupees ten lakh)only. The validity of the policy is from dt. 09-06-2019 to 08-066-2020. During the validity period of policy the Complainant's wife got left knee operation at Ashwini Hospital and the accordingly as the Opposite Party No.3(three) has provided the arrangement for cashless treatment the Complainant has submitted the bill of hospitalization charges of Rs. 2,65,330/-(Rupees two lakh sixty five thousand three hundred thirty)only but the Opposite Party No.2(two) has paid only Rs. 80,000/-(Rupees eighty thousand)only to the Complainant. The account statement filed by the Complainant as well as the mail of Opposite Party No.2(two) reflects that the Arogyadaan sum insured is of Rs. 10,00,000/-(Rupees ten lakhs)only.

            The policy is admitted, the hospitalization of the Complainant's wife is admitted but the Opposite Party No.2(two) did not settle the claim as per the sum insured of Rs. 10,00,000/-(Rupees ten lakh)only. It is the duty of Opposite Party No.2(two) to pay the remaining hospitalization charges to the Complainant. Non settlement of claim of the Complainant during the validity period of the policy amounts to deficiency in service on the part of the Opposite Party No.2(two). The issue is answered accordingly.

Issue No.2(two)

7)         As per supra discussion, the Complainant is entitled for relief claimed.

                        Accordingly it is ordered.

                                                            O  R  D  E  R

8)         The Complaint is allowed on contest against the Opposite Party No.2(two), is  dismissed against Opposite Party No. 1(one) and No.3(three). The Opposite Party No.2(two) is directed to pay the balance amount of Rs. 1,85,330/-(Rupees one lakh eighty five thousand three hundred thirty)only towards hospital charges along with Rs.20,000/-(Rupees twenty)only towards mental agony and Rs. 10,000/-(Rupees ten thousand)only towards litigation expenses to the Complainant within one month of this order, failing which, the entire awarded amount shall carry 12%(twelve percent) interest per annum till realization.

9)         Accordingly the order is pronounced in the open Commission to-day i.e.  Dt.04/03/2024 and the case is allowed against the Opposite Party No.2(two) and disposed off.

                                                                                             Typed to my dictation

                                                                                              and corrected by me.                                                                                                     

                                    I agree,                                                ( Smt. Anju Agrawal)

                                                                                                     M e m b e r(w).

                       (Smt. Jigeesha Mishra)

                              P r e s i d e n t.