Date of filing:- 08/09/2023.

Date of Order:-30/07/2024.

DISTRICT CONSUMER DISPUTE REDRESSAL COMMISSION

B A R G A R H (ODISHA).

Consumer Complaint No. 130 of  2023.

            Mst. Debaki Gartia wife of late Dinabandhu Gartia, aged about 67(sixty seven) years, resident of Beheratikira, W. No.4(four), Bargarh, Po/Ps and Dist. Bargarh.                                                                                                         .....       .....     .....         Complainant.

-: V e r s u s :-

1. Director, Operation and Customer Service, Niva Bupa Health Insurance Company Limited, Lagix Infotech Park, Plot No. D-5, Sector-59, Noida, Goutam Buddh Nagar, UP-201301.
2. Branch Manager, Bandhan Bank, Bargarh At- Bandutikra Chowk, Bargarh Po/Ps and Dist. Bargarh.
3. Bhabani Shankar Kisan son of Laxmi Kisan, resident of Jampali, Via. Kundukela, Dist. Sundargarh.
4. Director, Vikash-Multi Specialty Hospital, Bargarh, At- Barahagoda, Bargarh, Po/Ps and Dist. Bargarh-768028.                             ..... .....       .....   Opposite Parties.

Counsel for the Parties:-

For the Complainant :-            Sri Ashwini Panda, Advocate with associates.

For the Opposite Party No.1(one):-     Sri S.Panda, Advocate with associates.

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

For the Opposite Party No.3(three) and No.4(four):-  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.30/07/2024.                                 -: J   U  D   G  E  M  E  N  T:-

Presented by Smt. Jigeesha Mishra, President:-   

1)         The case of the Complainant is that the husband of the Complainant late Dinabandhu Gartia was a bonafide consumer of Opposite Party No.1(one), he has health insurance scheme for himself and for the Complainant bearing Policy No. 32426187202200, Member ID 13049493 and Claim ID No. 1003806 which covers up to ₹ 5,00,000/-(Rupees five lakh)only where the Complainant is the nominee. On 10^th July 2022, the husband of the Complainant was alright at about 5.30 AM after which he complained of felling of uneasiness associated with profuse sweating and loss of consciousness for few seconds, so immediately he was shifted to Vikash Multi-speciality Hospital, Bargarh where his treatment was continued. The patient so also the Complainant intimated the Opposite Party No.1(one) regarding the illness and treatment of the patient through Opposite Party No.3(three), who is the agent of Opposite Party No.1(one) on the very day i.e. on 10^th July 2022 the also on subsequent dates. Thereafter on 6^th day of the treatment on 15^th July 2022 the patient died. The expenditure towards the treatment of the patient is more than ₹ 3,00,000/-(Rupees three lakh)only wherein ₹ 2,41,162/-(Rupees two lakh forty one thousand one hundred sixty two)only has been spent for medical treatment vide Bill No. 1522/2022-2023 dated 15-07-2022 issued by Opposite Party No.4(four). The Complainant has paid the bills amount to Opposite Party No.4(four) where Opposite Party No.1(one) paid nothing after due intimations. When the Complainant claimed for the medical treatment amount of the patient as per bills amounting ₹ 2,41,162/-(Rupees two lakh forty one thousand one hundred sixty two)only, but the Opposite Party No.1(one) rejected the claim on the ground that mandatory documents have not received after repeated reminders, though the Complainant has submitted all relevant documents before Opposite Party No.1(one). Hence the Complainant filed this case before this Commission for deficiency in service of the Opposite Parties.

2)         The case of the Opposite Parties is that Opposite Party No.1(one) and Opposite Party No.2(two) filed their version. Opposite Party No.3(three) and Opposite Party No.4(four) did not appear and set ex-parte.

            The Opposite Party No.1(one) Niva Bupa Health Insurance Company Ltd admitted that the Opposite Party No.1(one) issued a policy bearing No. 32426187202200 to Mr. Dinabandhu Gartia and the Complainant Mrs Debaki Gartia for a period from 06-05-2022 to 05-05-2023 under Family Floater Plan for sum insured of ₹ 5,00,000/-(Rupees five lakh)only. The Opposite Party No.1(one) received the claim on behalf of Mr. Dinabandhu Gartia under the said health policy. However, upon investigation it was revealed that the cause of death was due increased ICP (intracranial pressure) with loss of brainstem and antecedent cause of death CAD (Coronary Artery Disease), HTN Hypertension with DM (Diabetes mellitus). The Complainant has never disclosed these facts at the time of taking the policy and deliberately concealed these relevant facts. Further the Opposite Party No.1(one) submitted that despite several request and reminders no information was provided by the Complainant. Accordingly the claim was rejected. The rejection of the claim was proper, legal, valid and justified. There is no any deficiency on the part of the Opposite Party No.1(one) and the complaint should be dismissed.

            The Opposite Party No.2(two), Bandhan Bank ltd submitted that there is no cause of action against Opposite Party No.2(two). The present complaint is misconceived as the Complainant has added Opposite Party No.2(two) in the instant case, however, entire allegations relates to medical insurance claim with respect to the said insurance claim which was issued by Opposite Party No.1(one) i.e. Niva Bupa Health Insurance Company Ltd. The Opposite Party No.2(two) further submitted that Bandhan Bank Ltd. is neither a necessary nor a proper party. In the entire complain petition the Complainant has not utter a single word against Opposite Party No.2(two). Hence the case should be dismissed against Opposite Party No.2(two).

3)         Perused the complaint petition, version and documents filed by the Parties and following issues are framed :-

Issues

1. Whether the Opposite Parties are deficient in service ?
2. Whether the Complainant is entitled to get relief ?

Issue No.1(one)

4)         The policy is admitted and insured admitted in Vikash Multi-Speciality Hospital, Bargarh during the currency of the policy on 10-07-2022 and died on 15-07-2022. The Complainant submitted policy paper, death certificate and bill of Vikash Hospital dated 15-07-2022 for an amount of ₹ 2,41,162/-(Rupees two lakh forty one thousand one hundred sixty two)only. The Opposite Party repudiated the claim on the ground that the Complainant had not submitted relevant documents and did not disclosed about pre-existing disease. It was the duty of the insurance company to conduct medical check up before insurance of policy. The Opposite Party No.1(one) has taken ₹ 78,587/-(Rupees seventy eight thousand five hundred eighty seven)only a huge amount of premium for health insurance from the insured, but at the time payment the Opposite Party No.1(one) is taking plea. When the policy is admitted and the insured admitted in hospital and died during the currency of the policy it was the duty of the insurance company Opposite Party No.1(one) to settle the claim. The Gurmel Singh Vrs National Insurance Co. ltd., Civil Appeal No. 4071 of 2022 the Hon'ble Supreme Court held that “while settling the claims, the insurance company should not be too technical and ask for the documents, which the insured is not in a position to produce due to circumstances beyond his control.”  In this case the Opposite Party No.1(one) repudiated the claim on the ground that the Complainant did not submit relevant documents which is improper. Non-settlement of claim of the Complainant amounts to deficiency in service on the part of the Opposite Party No.1(one). After perusal of record it is found that there is no cause of action against Opposite Party No.2(two), Bandhan Bank Ltd.. Hence the Opposite Party No.2(two) is not a proper party in this case. Opposite Party No.3(three) is the agent of Opposite Party No.1(one) and Opposite Party No.4(four) is the hospital where the insured threated. The present case is filed for insurance claim and due to the deficiency of Opposite Party No.1(one), the Complainant did not get her legitimate claim. The claim of the Complainant is against Opposite Party No.1(one) only. The Opposite Party No.2(two), No.3(three) and No. 4(four) have no liability in this case. The issue is answered accordingly.

Issue No.2(two)

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

            As per supra discussion the following order passed:-

                                                            O  R  D  E  R

6)         The Complaint is allowed on contest against the Opposite Party No.1(one) and dismissed against Opposite Party No.2(two), No.3(three) and No. 4(four). The Opposite Party No.1(one) is directed to pay the insurance claim of ₹ 2,41,162/-(Rupees two lakh forty one thousand one hundred sixty two)only  to the Complainant within one month from the date of this order. Further the Opposite Party No.1(one) is directed to pay ₹40,000/-(Rupees forty thousand)only compensation for deficiency in service and ₹ 10,000/-(Rupees ten thousand)only for litigation expenses to the Complainant, failing which, the entire awarded amount shall carry 12%(twelve percent) interest per annum till realization.

            Order pronounced in the open court on 30^th day of July 2024.

                        Supply free copies to the Parties.

                                                                                             Typed to my dictation

                                                                                              and corrected by me.

                                    I agree,                                              ( Smt.Jigeesha Mishra)

                                                                                                    P r e s i d e n t.

                       (Smt. Anju Agrawal)

                             M e m b e r(w).