Date of filing:- 12/01/2021.
Date of Order:-15/04/2024.
DISTRICT CONSUMER DISPUTE REDRESSAL COMMISSION
B A R G A R H (ODISHA).
Consumer Complaint No. 07 of 2021.
- Dr. Jaya Krishna Patel S/o Late Harihar Patel,
- Smt. Jyotsna Patel W/o. Dr. Jaya Krushna Patel,
Both Occupation- Doctor & House wife respectively, both R/o College Road, Padmapur, Po. Rajborasambar, Dist. Bargarh. ..... ..... Complainants.
-: V e r s u s :-
- The Chief Regional Manager, L.I.C. of India, Divisional Office, Sambalpur, At- Jivan Prakash Building, Ainthapali, Samablpur, Po/Ps/Tahasil/Dist. Sambalpur.
- The Manager, Health Insurance L.I.C. of India, Divisional Office, Sambalpur, At/Po/Ps/Dist. Sambalpur. ..... ..... ..... Opposite Parties.
Counsel for the Parties:-
For the Complainants :- Sri S.Sahu, Advocate with associates.
For the Opposite Parties :- Sri D.Mishra, Advocate.
-: 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.15/04/2024. -: J U D G E M E N T:-
Presented by Smt. Jigeesha Mishra, Member(w):-
1) The case of the Complainants is that the Complainants are husband and wife. The Complainant No.1(one) namely Jaya Krishna Patel is closely related with the Opposite Parties corporation since last 20(twenty) years being the Medical Examiner of the Corporation of Padampur Branch. The Complainants have insured their health by a health insurance policy under L.I.C.'s Jeevan Arogya Scheme bearing Policy No. 594872229 on 15-12-2016 which covers both husband and wife. Unfortunately the Complainants have met with an accident on 14-06-2017 wherein they sustained multiple injuries on their person. They were initially admitted in the S.D. Hospital, Padampur for first aid treatment where from they were referred to V.S.S. Medical College Hospital, Burla. For their treatment M.L.C. report has been submitted by Sri K.C.Meher, M.O., S.D.H., Padampur to the I.I.C., Padampur Police Station on 17-04-2017 on which Padampur P.S. Case No. 113 of 2017 has also been registered. The Complainants for better treatment have been admitted into Gupta Nursing Home, Burla and undergone treatment therein. The Complainants have claimed for insurance benefit entitled under the policy. Accordingly they have submitted all the relevant documents along with the claim application as per the requirements of Opposite Parties through their L.I.C. Agent Sri Shishir Kumar Panda. After discharge from hospital about one year after the Complainant No.1(one) has received a sum of Rs. 60,000/-(Rupees sixty thousand)only against hospital stay at the rate of Rs. 4,000/-(Rupees four thousand)only per day for 15(fifteen) days. But the Complainant No.2(two) has not received any amount against hospital stay. The Complainant approached several times. At last the Complainant sent pleader notice on 09-09-2020 to the Opposite Parties. The Opposite Parties have received the notice but remained silent. Hence the Complainants filed this case before this Commission for deficiency in service of the Opposite Parties.
2) The case of the Opposite Parties is that the Opposite Parties filed their version. The Opposite Parties submitted that the case is barred by limitation because the claim of this case relates to treatment of the Complainant No.2(two) from 15-06-2017 to 30-06-2017 but the case is filed by the Complainants on 12-01-2021. Hence this case is liable to be dismissed. The Opposite Parties further submitted that the Opposite Parties had asked the Complainants to submit necessary documents regarding their treatment and on receipt of documents submitted by the Complainants the Opposite Parties found that the Complainants had been admitted in Gupta Nursing Home for general treatment where no surgery was performed on either of the Complainants as reported by the TPA (Third Party Administrator). Hence only HCB (Hospital Cash Benefit) for 15(fifteen) days @ Rs.4,000/-(Rupees four thousand)only per day i.e. Rs. 60,000/-(Rupees sixty thousand)only was paid to the Complainant No.1(one) Jaya Krishna Patel on 12-11-2018. In case of Complainant No.2(two) the TPA has reported that no operation was performed on her. The Health Insurance Department at Divisional Office, Sambalpur had called for DMR Divisional Medical Referee report on the matter. After verification the DMR report reveals that operation was performed. On the basis of DMR report the claim has been put up before DODRC (Divisional Office Disputes Redressal Committee) which recommended for payment. Latter the recommendation of the DODRC decision was sent to the TPA and the Opposite Parties paid a total sum of Rs. 1,80,000/-(Rupees one lakh eighty thousand)only i.e. Rs. 60,000/-(Rupees sixty thousand)only towards HCB for 15(fifteen) days @ Rs. 4,000/-(Rupees four thousand)only per day and Rs. 1,20,000/-(Rupees one lakh twenty thousand)only OSB (Other Surgical Benefits) on 19-04-2021. The entire claim amount has already been paid to the Complainants. Hence there is no deficiency on the part of the Opposite Parties and the Opposite Parties prayed for dismissal of the case.
3) After perused the complaint petition, version and documents filed by the Parties following issues are framed.
Issues
- Whether the Complaint is barred by limitation ?
- Whether the Opposite Parties are deficient in service ?
- What the Complainants are entitled to get relief ?
Issue No.1(one)
The Opposite Parties submitted that the case is barred by limitation as the case relates to treatment of the Complainant No.2(two) from 15-06-2017 to 30-06-201 but the case is filed on 12-01-2021. After perusal of record it reveals that the case is related to payment of insurance claim when the payment was not made the Complainant served a pleader notice on 09-09-2020 which is attached as document in the case record. When the Opposite Parties did not paid the insurance claim the Complainants filed the case on 12-01-2021 within two years from the date of service of pleader notice. Hence the case is not barred by limitation. The case is maintainable. The issue is answered accordingly.
Issue No.2(two)
The Opposite Parties admitted that the Complainants were admitted for treatment in Gupta Nursing Home. As per the submission of the Opposite Parties Rs. 60,000/-(Rupees sixty thousand)only was paid to the Complainant No.1(one) Jaya Krishna Patel on 12-11-2018 and Rs. 1,80,000/-(Rupees one lakh eighty thousand)only was paid for the treatment of Complainant No.2(two) on 19-04-2021. The Complainants admitted the payment of Rs. 60,000/-(Rupees sixty thousand)only but the Complainant filed this case for non payment of claim of Complainant No. 2(two). After perusal of record it reveals that the Opposite Parties field a letter dated 30-04-2021 about payment of Rs. 1,80,000/-(Rupees one lakh eighty thousand)only. The letter was issued by Manager (HI), LIC of India, Division Office, Sambalpur. But no document was filed regarding payment. When the payment was made it was the duty of the Opposite Parties the prove that the payment was made. The Opposite Parties did not file any document regarding payment. Mere submission is not acceptable. Hence the submission of the Opposite Parties without proof is not acceptable. The Opposite Parties paid payment on 12-11-2018 to the Complainant No.1(one) for the period of treatment from 15-06-2017 to 30-06-2017. The Opposite Parties paid payment but there is delay in payment. Delay in payment is also a deficiency on the part of the Opposite Parties. The issue is answered accordingly.
Issue No.3(three)
For deficiency in service of the Opposite Parties the Complainants are entitled to get relief. The issue is answered accordingly.
As per supra discussion the following order is passed :-
O R D E R
6) The Complaint is allowed on contest against the Opposite Parties. The Opposite Parties are directed jointly and severally to pay Rs. 1,80,000/-(Rupees one lakh eighty thousand)only to the Complainants within one month from the date of this Order. Further the Opposite Parties are directed to pay Rs.30,000/-(Rupees thirty thousand)only compensation for deficiency in service and Rs. 5,000/-(Rupees five thousand)only for litigation expenses to the Complainants, failing which, entire awarded amount shall carry 12%(twelve percent) interest per annum till realization.
7) Accordingly the order is pronounced in the open Commission to-day i.e. Dt.15/04/2024 and the case is allowed against the Opposite Parties and disposed off.
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).
