Date of filing:- 17/03/2017.
Date of Order:-19/02/2020.
DISTRICT CONSUMER DISPUTES REDRESSAL FOURM(COURT)
B A R G A R H
Consumer Complaint No. 13 of 2017
Sanjay Kumar Gupta, aged about 43(forty three) years, Son of Mangeram Gupta, Occupation- Business, Resident of Ward No.19(nineteen), near Railway Station, Bargarh, Po. Bargarh, Ps. Bargarh(Town), Dist. Bargarh. ..... ..... ..... .... Complainant.
-: V e r s u s :-
Oriental Insurance Co. Ltd. represented through Senior Divisional Manager, Oriental Insurance Co. ltd. At V.S.S.Marg, Sambalpur, Po/Ps-Sambalpur (Town), Dist. Sambalpur.
The Branch Manager, Oriental Insurance Co. ltd., At. Canal Avenue, Ward No.16(sixteen), Near Private Bus stand, Bargarh, Po. Bargarh, Ps. Bargarh(Town) Dist. Bargarh.
M/s Medi Assist India, represented through its Branch Manger, At- 4/1 IBC Knoledge Park, Tower “D”, 4th Floor, Bannerghatta Road, Bangalore-560029. ..... ..... ..... Opposite Parties.
Counsel for the Parties:-
For the Complainant :- :- Sri L.Behera, Advocate with associate Advocates.
For the Opposite Parties:- :- Sri P.K. Mahapatra, Advocate.
-: P R E S E N T :-
Sri Krishna Prasad Mishra ..... ..... ..... ..... ..... P r e s i d e n t.
Ajanta Subhadarsinee ..... ..... ..... ..... ..... M e m b e r (W).
Dt.19/02/2020. -: J U D G E M E N T:-
Presented by Sri Krishna Prasad Mishra, President:-
Brief Facts of the case ;-
The Complainant being persuaded with the provision U/s 12 of the Consumer Protection Act 1986 has preferred to file the case with an allegation of deficiencies of service and unfair trade practice against the Opposite Parties on the ground mentioned hereunder.
The case of the Complainant is that he being allured with scheme of the Opposite Party purchased a med claim policy from the Opposite Party No.1(one) to get Mediclaim coverage for himself and also his family members with an assurance by the Opposite PartyNo.1(one), that the Opposite Party No.3(three) would provide him service and as such paid his premium of the said insurance policy on good faith that the same policy would cover against any decease if occurred with anybody of his family members, also it is his case that at the time of his such entrance with the policy of the Opposite Party No.1(one) he was not informed of the coverage limit of the same with regard to any decease, and was also issued with a Royal Mediclaim Policy by the Opposite Parties vide policy No-345600/48/2016/622 with a coverage period from Dt.01.08.2015 to mid night Dt.31.07.2016 with a Mediclaim coverage to his family members such as his wife, son and his daughter.
In furtherance to his case during the subsistence of the said policy period his wife became seriously ill on Dt.04.03.2016 and was admitted in the Department of Hematology of Christial Medical College, IDA Scudder Road Vellore-632004, India for her treatment and during the treatment it was detected that she was suffering from Aplastic Anema and treated thereto and was discharged from there on Dt.31.03.2016 whereby the Complainant had to spend an amount of Rs.8,85,119/-(Rupees eight lakh eighty five thousand one hundred nineteen)only thus after being discharged the Complainant claimed for the said amount from the Opposite Parties submitting his all relevant documents with bills against his said policy but they did not turn up even after several request and reminder consequent upon which he has to undergo with financial mental and physical harassment as such has claimed that such action of the Opposite Parties amounts to deficiencies of service and unfair trade practice on their part being liable for the same jointly and severally and has claimed an amount of Rs.9,99,119/-(Rupees nine lakh ninety nine thousand one hundred nineteen)only against his expenses amounting to Rs.8,85,119/-(Rupees eight lakh eighty five thousand one hundred nineteen)only towards the treatment of his wife and an amount of Rs.99,000/-(Rupees ninety nine thousand)only towards compensation for his sufferings, and in substantiating his case has relied upon the following Documents:-
Xerox copy of Mediclain Policy bearing No.345600/48/2016/622.
Original Office copy of letter 27th day of June 2016.
Original Postal Receipt Dt.27/06/2016.
Original Postal A.D..
Xerox copy of Medical Bills.
Perused the complaint petition and the documents filed along with the same and on hearing the learned counsel for him the case was admitted and notice was served on the Opposite Parties and in response all the Opposite Parties appeared before the Honorable Forum but the Opposite Party No.1(one) & No. 2(two) only filed their respective version through their Advocate and in spite of several time was allowed to the Opposite Party No.3(three) he did not file his version as such the Forum was pleased to take up the case for hearing on merit on the basis of the version of the Opposite Party No.1(one) & No.2(two) and other material available in the record. And so far the version of the Opposite Party No.1(one) & No.2(two) is concerned the same are all denial to the case of the Complainant stating therein that the case is not maintainable and beside that also raised the question of jurisdiction of the Forum in view of the elaborate evidence and in-depth scrutiny and discussion of the case is required to adjudicate the case.
And in furtherance to their joint pleas, they are not to be liable for any action under the Act as the same policy is bound by certain terms and conditions, wherein it has stated that the policy was issued in his favor by the Opposite Party No.3(three) and agree to render service by the Opposite Party No.3(three) as has been claimed by the Complainant but with certain terms and condition, under which the claim does not comply with the exclusion of the policy u/clause 4(1) of the policy schedule for which is not entitled for any claim to which after verification the Opposite Party No.3(three) has already denied as the same terms condition is accepted by the Complainant at time of executing the proposal.
Furthermore the Complainant has insured under the Med-claim policy for a sum assured of an amount of Rs.5,00,000/-(Rupees five lakh)only for which the Opposite Parties are not liable to pay the claim amount of Rs.9,99,119/-(Rupees nine lakh ninety nine thousand one hundred nineteen)only besides some other exclusion in the policy thereby the claim of the Complainant is not maintainable against the Opposite Parties, and the same is liable to be dismissed in support of the case the Opposite Parties and in order to prove their case have filed the following documents, i.e. (i) the true copy of the Insurance Policy bearing No-345600/48/2016/622 (nineteen sheets) (ii) Letter of Opposite Party No.3(three) issued to Opposite Party No.1(one), (two sheets).
During the course of hearing of the case the Learned Counsels of the respective Parties placed their arguments vehemently in support of their respective pleas before the Honorable Forum in addition to that the Advocate for the Complainant has also filed a written notes of arguments along with some decision of the National Commission in support of his case. And on the verge of the pronouncement of the Order the learned counsel for the Opposite Parties filed a notes of arguments citing some decisions of the Honorable Supreme Court and Honorable National Commission so though it was too late we felt it to be better for more appreciations of the case so accepted the same and incorporated in the record and as the power supply to the forum was also disrupted through out the working hour of the day as such we had to defer the date of pronouncement of the order to Dt.19.02.2020.
Perused the pleadings of the parties and their respective documents vividly and on hearing the learned counsels for the Parties from where it reveals that the case of the Complainant is admitted by the Opposite Parties to the extent of his having the said policy issued by the Opposite Parties by paying the requisite amount of premium for one year i.e. from Dt.01.08.2015 to mid night Dt.31.07.2016 also it reveals from the record that the wife of the Complainant has undergone for the said treatment for Aplastic Anema and was admitted in the Hospital namely Department of HEMATOLOGY at CHRISTIAL MEDICAL COLLEGE, IDA SCUDDER ROAD VELLORE, but the only point of arguments of the Opposite Parties is with regard to the exclusion clause of 4(1) whereby as per their claim the same diseases is not coming under the said policy as per the terms and condition envisaged in the policy, but in this regard to our observation it has come to our notice that the Complainant has explained in his pleadings that the terms and condition of the said policy was not known to him and also the same was not read over and explained to him by any of the Opposite Parties while taking his signature on the application form of the insurance as per him, and also we did not find any such statement from the Opposite Parties anywhere that the same terms and condition has been explained to the Complainant at the relevant time of execution of the proposal of the policy which ought to have been as duty bound particularly because of the complainant being a member of a common category people of the society and further more it is observed from the materials available before us that such a voluminous documents in relation to the policy can never be gone in to and cannot be understood by any lay men unless being clearly read over and make him understood by the Opposite Party concerned but here as we have stated it is not available before us to that effect which has been also fortified by the citation of the Honorable National Commission reported in 2017 (vol-2) C.P.R Page No.560 and Page No.467(NC), wherein it has been clearly held by their lordship that terms and condition if anything of that sort is there it must be clearly explained to the proposer before accepting the same but in the present case it has not been followed as such in view of such circumstances we are of the view that the claim of the Complainant cannot be repudiated by Opposite Parties, further more such an expression of the Honorable National commission left no space of ambiguity to refer to the decision cited by the Opposite Parties in detail the hence our view is expressed in favor of the Complainant with an observation that the disease undergone by the wife of the Complainant does not come under the exclusion clause of the policy schedule.
And also in furtherance to our observation, it is clearly declared in the proposal form of the Complainant that there is no such pre-existing diseases with any members of his family to which the Opposite Parties have accepted so their allegation of suppression of the pre-existing disease of the same is not sustainable in repudiating the claim of the Complainant by the Opposite Parties. And be it pertinent to mention that the very failure of filing the version by the Opposite Part No.3(three) before the Forum even if sufficient time was allowed to him, who is said to have been the service provider, has made us believe the claim of the Complainant to be a genuine one. Hence answered accordingly in support of the Complainant.
In furtherance to our observation it has been claimed by the Opposite Part with regard to the amount of claim of the Complainant for the expenses made by him stating therein that the Complainant has undergone with a policy for a sum assured amount of Rs.5,00,000/-(Rupees five lakh)only and has accordingly paid the premium as such the Complainant cannot go beyond sum assured amount of the policy in support of which the learned counsel has relied on a decision of the honorable National commission reported in the year 2017(2) C.P.R.page 117, in this regard to our observation from the Policy bond it is a fact that the sum assured amount of the Policy is worth of Rs.5,00,000/-(Rupees five lakh)only as such an excess amount beyond the sum assured amount cannot be claimed but for such reason the total legitimate claim of the Complainant cannot be repudiated, hence our view is expressed accordingly in favor of the Complainant.
And in view of our narrative discussion of the materials facts available in the record and our opinion thereto, we are of the view that the repudiation of the claim of the Complainant by the Opposite Parties, amounts to deficiencies of service coupled with unfair trade practice on their part for which all the Opposite Parties are jointly and severally liable, hence our Order follows.
O r d e r
The Opposite Parties are being jointly and severally liable for the Claim of the Complainant are directed to pay him an amount of Rs.5,00,000/-(Rupees five lakh)only with an interest @ 6% (six percent) per annum from the date of filing of the case till date of this Order and also are directed to pay him an amount of Rs.50,000/-(Rupees fifty thousand)only as compensation towards his mental and financial harassment within thirty days of receipt of the order in default of which all the total amount would carry an interest @ 9 % (nine percent) per annum till the actual realization of the total amount.
In the result the Complaint is allowed against the Opposite Parties, and the same being pronounced in the open Forum is disposed off to-day i.e. on Dt.19.02.2020.
Typed to my dictation
and corrected by me.
( Sri Krishna Prasad Mishra)
P r e s i d e n t.
I agree,
( Ajanta Subhadarsinee)
M e m b e r (W).
Uploaded by
Sri Dusmanta Padhan
Office Assistant, Bargarh.
