Date of filing:- 01/01/2021.                                                                                                                                                                                                              Date of Order:-11/07/2023.

DISTRICT CONSUMER DISPUTE REDRESSAL COMMISSION,

B A R G A R H.

Consumer Complaint No.   1 of 2021.

Roshni Pradhan, aged about 30 years, Daughter of Suresh Chandra Pradhan, Resident of Rengalpali, Near Ekambra Chowk, Bargarh (Sadar) Po/Dist. Bargarh 768028.

                                                                                                     Complainant.

V e r s u s

1. Care Health Insurance Pvt. Ltd, (formerly known as Religare Health Insurance Pvt. Ltd) represented through its  Managing Director, Care Health Insurance Pvt. Ltd, Unit No. 604-607, 6th  Floor, Tower C, Unitech Cyber Park, Sector 39, Gurgaon 122001.
2. Continental Automotive Brake System India Pvt. Ltd, represented through its Managing Director, Plot No. 179 180, Sector 5, IMT Manesar, Gurgaon, Haryana, Maharastra, Mumbai 40001.
3. Purohit General Hospital and Research Centre, represented through Dr. Rama Krushna Purohit, Shakti Nagar, N.H.6, Bargarh 768028.                                                                                                                                      

                                                                                                                    Opposite Parties.                         

Counsel for the Parties:-

For the Complainant :-                   :- Sri S.K. Pradhan with  Advocates.

For the Opposite Party No.1 :-       :- Sri Ashok Kumar Dash, Advocate.

For the Opposite Party No.2 & 3   :- Ex-parte.

                                                -: 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.11/07/2023.                                 -: J   U  D   G  E  M  E  N  T:-

Presented by Smt. Jigeesha Mishra, President :-

1. The Case of the Complainant is that the Complainant is an employee of Opposite Party No.2 and she was working as a senior engineer from 2013 to 2018. During tenure of her service with Opposite Party No.2 the Complainant with due payment of premium, became a member of the Group insurance policy taken for its employee by the Opposite party No.2 from the Opposite Party No.1 bearing Group Insurance policy No. 11735539 and the Complainant  and her father namely Suresh Chandra Pradhan are covered under the benefit of such policy. While the policy was in force the father of the Complainant met with an accident and sustained injuries of Communited fracture of right tibia, fracture of fibula with cellulitis on his person. Her father admitted on 15/11/20217 for the purpose of treatment in the hospital of Opposite Party No.3 vide registration No. 1748/11/2017 and discharged on 06/01/2018 from the hospital. The Complainant spent a sum of  Rs. 1,29,500/-(Rupees one lakh  twenty nine  thousand five hundred)only  for  treatment of her father. The Complainant lodged claim with the Opposite Party No.1 and submitted all relevant documents for reimbursement of the aforesaid amount. The claim of the Complainant has been allotted with claim No. 90505456-01 by the Opposite Party No.1. But the Opposite parties No.1 repudiated the claim of the Complainant on false and fictitious ground of Deficiency not Replied vide its letter Dt. 28/08/2018. The Complainant approached the Opposite Party No.1 several times for settlement of the claim, but Opposite Party No.1 remained silent. Hence the Complainant filed this case before this Commission.
2. The Case of the Opposite Parties is that, Opposite party No.1 filed its version and admitted about the issuance of policy bearing no. 11735539. The Opposite Party No.1 submitted that the case is not maintainable on the point of limitation. Further the Opposite party No.1 submitted that the insurance company raised deficiency letter dated 12/02/2018, 26/02/2018 and reminders dated 22/02/2018, 08/03/2018, 16/04/2018. The Company did not receive any satisfactory reply. Hence the Opposite Party No.1 repudiated the claim of the Complainant on the ground DEFICIENCY NOT REPLIED  and intimated it vid letter dated 28/08/2018.

Hence there is no deficiency on the part of the Opposite Party No.1 and the Opposite Party No.1 prayed for dismissal of the case.

3. Perused the Complaint petition, version and document filed by the parties and following issues are framed:-

1.Whether the case is barred by limitation?

2. Whether the Opposite Parties are deficient in service ?

3. What relief the Complainant is entited to get ?

Issue No.1.

            The Opposite Party No.1 submitted that the Complainant is barred by limitation as the Complaint has filed after 2 years and 6 months from the date of rejection letter 28/08/2018. The Complainant in her Complaint petition submitted that due to COVID 19  Lockdown situation she could not able to come from her working place at Hydrabad to Bargarh. Hence the Complainant could not file the case and prayed for condonation of  delay. In this situation the delay is condoned and the case is not barred by limitation. The issue is answered accordingly.

Issue No.2.

Perused the record and it reveals that there is no cause of action against Opposite Parties No.2 and 3. Accordingly the case is dismissed against Opposite Party No.2 and 3. The insurance policy is admitted, accident is admitted. The Complainant submitted money receipt of  Rs. 1,29,500/-(Rupees one lakh  twenty nine  thousand five hundred)only of dated 06/01/2018 for medical treatment of her father. But the Opposite Party No.1 repudiated the claim and taking plea that there is no deficiency on the part of Opposite Party No.1, Non settlement of claim by Opposite party No.1 amounts to deficiency in service of  Opposite Party No.1. The issue is answered accordingly.

Issue No.3.

            For deficiency in service of the Opposite Party No.1 the Complainant is entitled to get relief. The issue is answered accordingly.

            As per supra discussion the following order is passed.

O R D E R

The Complaint is allowed on contest against Opposite Party No.1 and  dismissed against Opposite Party No.2 and Opposite Party No.3. The Opposite No.1 is directed to pay  Rs. 1,29,500/-(Rupees one lakh  twenty nine  thousand five hundred)only to the Complainant within 30 days of this order.

            Further the Opposite Party No.1 is directed to pay Rs. 30,000/-(Rupees thirty thousand)only compensation for harassment and mental agony and Rs.5,000/-(Rupees five thousand)only for litigation expenses to the Complainant.

Failing which the entire amount will carry 12% interest P.A. till realization.

Order pronounced in open court on this  11^th    day of  July 2023.

            Supply free copies to the parties. 

      Typed to my dictation

                                                                                           and corrected by me.                                                                                            

                   I  agree/-                                                                       

       ( Smt. Anju Agrawal )                                                                  ( Jigeesha Mishra )

              Dt.11/07/2023                                                                            Dt.11/07/2023

              M e m b e r  (w)                                                                        P r e s i d e n t.