Date of filing:- 07/10/2021.
Date of Order:-19/02/2024.
DISTRICT CONSUMER DISPUTE REDRESSAL COMMISSION
B A R G A R H (ODISHA).
Consumer Complaint No. 56 of 2021.
Sri Jay Gopal Sharma, S/o Late Nand Lal Sharma, aged about 45(forty five) years, R/o. Ward No. 10(ten), Ganesh Nagar Laderpali, Attabira, Occupation-Doctor, Ps,-Attabira, Dist. Bargarh.
..... .... ..... Complainant.
-: V e r s u s :-
- The Managing Director, Star Health and Allied Insurance Company Ltd., At- 1, New Tank Street, Valluvar Kottam High Road, Nugambakkam, Chennai-600034.
- The Branch Manager, Star Health and Allied Insurance Company Ltd., Sambalpur Branch, At-2nd Floor, Quality Mansion, Nayapara, Sambalpur-768001.
..... ..... ..... Opposite Parties.
Counsel for the Parties:-
For the Complainant :- Sri S.B.Mishra, Advocate with associates.
For the Opposite Parties :- 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.19/02/2024. -: 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 is a doctor and has purchased one health insurance plan from the Opposite Party No.2(two) bearing policy No. P/191214/01/2020/004408 and the said policy was meant for covering health insurance plan for the Complainant and has family members. The said policy was valid from 31-03-2020 to midnight of 30-03-2021. The Complainant due to worse health condition got himself admitted on dt. 22-10-2020 in Vikash Multi Speciality Hospital at Barahagoda Canal Road, Bargarh and was discharged on 28-20-2020 with a diagnosis that he was suffering from BILATERAL PNEUMONIA. Before admission the Complainant has undergone RTPCR test and the test was negative. For the said treatment, the Complainant had paid Rs. 1,40,000/-(Rupees one lakh forty thousand)only and for the insurance claim the Complainant had filed claim of reimbursement and the claim was registered as claim Intimation Number – CIR/2021/191214/0423904 Dt. 28-10-2021 before the Opposite Party No.2(two). On dt. 25-12-2020, the Opposite Party No.1(one) has rejected the claim that the Complainant has undergone treatment of Covid-19. Despite repeated request the Opposite Parties rejected the claim when the insurance policy is in validity period. For the deficiency in service committed by the Opposite Parties the Complaint is filed by the Complainant with a prayer that Opposite Parties be directed to pay Rs. 1,40,000/-(Rupees one lakh forty thousand)only for the medical expenses and to pay a sum of Rs. 3,60,000/-(Rupees three lakh sixty thousand)only for compensation towards mental agony and physical harassment.
2) The case of the Opposite Parties is that the Opposite Parties did not appear before this Commission to file version. Hence, Opposite Parties are set ex-parte.
3) The Complainant to substantiate his claim has filed them following documents.
a) Copy of Insurance Policy of Family Health Optima Insurance Plan bearing Policy No. P/191214/01/2020/004408.
b) Copy of claim rejection report of Opposite Party No.1(one) dated 25-12-2020.
c) Copy of discharge certificate of Vikash Hospital, Bargarh.
d) Copy of Final Medical Expenditure Bills of Vikash Hospital.
e) Copy of E-mail of Complainant dated 05-05-2021.
f) Copy of grievance dept. pf Opposite Parties dated 15-05-2021.
g) Copy of RTPCR report of Complainant.
4) Perused the documents filed by the Parties and following issues are framed:-
Issues
- Whether the Opposite Parties are deficient in their service ?
- What relief the Complainant is entitled for ?
Issue No.1(one)
5) After perusal of the documents, it reveals that the Complainant was admitted in Vikash Multi Hospital the date of admission being 22-10-2020 and date of discharge being 28-10-2020. During that period policy was valid from 31-03-2020 to midnight of 30-03-2021 when the Complainant claimed the hospitalization charges the Opposite Party No.1(one) has rejected the claim that the Complainant was seeking reimbursement of hospitalization expenses for treatment of Covid-19 but the discharge of the Vikash Hospital reflects that the Complainant was diagnosed with Bilateral pneumonia and was Covid-19 (-ve). As the Complainant was not suffering from Covid-19, mere rejecting the claim when the policy is under the validity period is not acceptable at all. The Complainant has further submitted the Covid-19 negative report to substantiate the claim. The Opposite Parties in the name of AIIMs Covid-19 guidelines cannot escape from the liability and to repudiate the insurance claim.
As the Opposite Parties has deducted Rs. 19,872/-(Rupees nineteen thousand eight hundred seventy two)only as premium for the policy bearing No. P/191214/01/2020/004408 and the said policy is under the validity period, the insurance coverage is of ten lakhs, the Complainant is entitled for insurance claim. Non settlement of claim by the Opposite Parties during the validity period of policy amounts to deficiency in service on the part of the Opposite Parties.
6) As per supra discussion, the Complainant is entitled for relief claimed.
Accordingly it is ordered.
O R D E R
7) The Complaint is allowed ex-parte against the Opposite Parties. The Opposite Parties are jointly and severally directed to pay medical expenses of Rs.1,40,000/-(Rupees one lakh forty thousand)only vide policy No.P/191214/01/2020/004408 along with Rs. 30,000/-(Rupees thirty thousand)only for mental harassment 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.
8) Accordingly the order is pronounced in the open Commission to-day i.e. Dt.19/02/2024 and the case is allowed against the Opposite Parties 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.
