Date of filing:- 10/05/2019.

                                                                                                    Date of Order/Judgement:-30/01/2023.

DISTRICT CONSUMER DISPUTE REDRESSAL COMMISSION,

B A R G A R H.

Consumer Complaint No. 34 of 2019.

                 Balakrushna Tiwari, S/o. Sarabjit Tiwari, aged about 55 years, resident of Sribash Food, Ulba, Po. Govindpur, Via. Sohela, Ps/Dist. Bargarh (Odisha).  

                                                                                                                                                                                                                                                                           Complainant.

V e r s u s

1. The Divisional Manager, Chola Insurance Xpress, Sambalpur Corporate Office, SRTT Colony, Budhraja, Sambalpur. Ps./Tahasil/Dist. Sambalpur 768004 (Odisha)
2.  The General Manager, Cholamandalam General Insurance Ltd, Now No. 319, Old No. 154, Shaw Waliance Building 2nd Floor Tambu Chetty Street, Parrys Corner, Chennai Pin 600001(Tamilnadu)
3. The Branch Manager, Cholamandalam Insurance Ltd, At.Bandutikra Chowk, Bargarh, Po/Ps./Dist. Bargarh.

                                                                                                                                                            Opposite Parties.                         

Counsel for the Parties:-

For the Complainant :-                       :- Sri M.K. Satpathy and  Associates.

For the Opposite Party No.1,2 and 3 :- Sri Ashok Kumar Dash and Associates.

                                                -: 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.30/01/2023.                                 -: 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 Balakrushna Tiwari is a bonafide policy holder of  Cholamandalam policy No. 2868/00126373100010. For the policy the Complainant has also been paying the requisite premium regularly towards personal health. The Complainant all of a sudden suffered heart problems and become serious while the policy was intact with all formalities. The Complainants was treated in K.G.M.U. Lucknow Hospital by specialized doctors of cardiology. In his treatment the Complainant has spent Rs. 55,878/-(Rupees fifty five thousand eight hundred seventy eight)only as net bill besides he has also met with various other expenses. The Complainant being a policy holder is entitled for the insurance claim and he furnished relevant documents as desired by the Opposite Parties but the Opposite parties did not settle the claim of the Complainant on  some false, imaginary, baseless reason. The  Complainant has also raised grievances before then time and again other telephone but they did not pay need and finally repudiate the claim vide letter Dt. 01/12/2018. Finding no way out, the Complainant served pleaders notice on Dt. 15/04/2019 to the Opposite parties for settling the claim but the Opposite parties remained silent.

Being aggrieved the Complainant filed this Complaint before this Commission. 

2. The Case of the Opposite parties is that the Opposite parties in his version submitted that group Health insurance policy was issued by the Cholamandalam  M/s General insurance Co.Ltd through the master policy No. 2868/00126373/000/00 to M/s Indusind Bank Ltd and the Complainant Balakrushna Tiwari being a loan Account holder of Indusind bank Ltd was extended with the Group Health Insurance policy for the Sum insured of Rs. 30000/-(Rupees thirty thousand) only vide certificate No. 2868/00126373/0470/000/00. The policy was valid from period 13/09/2017 to 12/09/2018. The policy also extends to the wife of the insured Balakrushna Tiwari wife for a total sum of Rs. 30000/-(Rupees thirty thousand) only for both insured and the wife. The Opposite party further submitted that the insured Balakrishna Tiwari was treated for coronary artery disease and the insured as per the documents submitted was a known case of hypertension, a query was raised but there was no information from the side of the insured and hence the insurance company closed the claim under intimation to the insured. The Complainant is not entitled for only amount from the insurance company. There is no deficiency in service from the Opposite party.
3. Perused the documents filed by the Complainant and Opposite parties and following issues are framed.

1. Whether the Complainant is a Consumer of the Opposite parties ?
2. Whether the Opposite parties are deficient in their service ?
3. What relief the Complainant is entitled to get ?

Issue No.1.

            The Complainants Balakrishna Tiwari has paid Rs. 780/-(Rupees seven hundred eighty)only for the period from 13/09/2017 to 12/09/2018 towards provision for  health insurance policy. Accordingly, the Complainant is the Consumer of the Op.

Issue No.2.

            The Opposite Party in its version submitted that the Complainant has not provided necessary documents regarding the settlement of the claim. The Complainant is a policy holder of cholamandalam vide policy no. 2868/00126373/000/00. The Complainant got heart problem all of  a sudden and  the Complainant was treated by specialized doctors of cardiology of K.G.M.U. Hospital Lucknow.  After being discharged from the said hospital the Complainant submitted all the relevants documents regarding the claim but the Opposite Party failed to settle the claim. The Complainants again sent a pleader notice on Dt 15/04/2019 but they remained silent. Non settlement of claim amount to deficiency in service on the part of the insurance company.

Issue No.3.

            The Complainant submitted the bill of hospital charges for Rs.55,878/-(Rupees fifty five thousand eight hundred seventy eight)only. The policy is insured for Rs. 30,000/-(Rupees thirty thousand) only as per the version of Opposite party. The Complainant is entitled for the sum claimed. Accordingly  the following order is made.

O R D E R

The Complaint is allowed on  contest against Opposite party. The Opposite party is directed to pay Rs.30,000/-(Rupees thirth thousand)only to the Complainant along with 9% intrest P.A. from the date of repudiation i.e. 01/12/2018 only to the Complainant within one month of this order, failing which the amount will carry 12% interest till realization.

Further Opposite party is directed to pay Rs. 10,000/-(Rupees ten thousand)only compensation towards mental harassment and 5,000/-(Rupees five thousand)only towards litigation costs.

Order pronounced in open court on  30^th day of January 2023.

            Supply free copies to the parties.

      Typed to my dictation

                                                                                            and corrected by me.                                                                                            

             I  agree/-                                                                       

      ( Smt. Jigeesha Mishra)                                                               (Anju Agarwal)

              Dt.30/01/2023                                                                         Dt.30/01/2023.

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

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