Date of filing:- 23/06/2022.

Date of Order:-30/04/2024.

DISTRICT CONSUMER DISPUTE REDRESSAL COMMISSION

B A R G A R H (ODISHA).

Consumer Complaint No. 17 of  2022.

            Santosh Kumar Barik, S/o Late Dasarath Barik, R/o Ward No.3(three), Bargarh, Po/Ps/Tahasil/Dist. Bargarh (Odisha)                  .....               .....        .....             Complainant.

-: V e r s u s :-

1. The General Manager, Star Health & Allied Insurance Company Ltd., Bo. 15, Sri Balaji Complex, 1^st Floor, Whites Lane, Royapettah, Chennai-600014.
2. The Branch Manager, Star Health & Allied Insurance Company Ltd., Branch Office, Sambalpur, 2^nd Floor, Quality Mansion, Nayapara, Sambalpur-768001.

       .....            .....       .....             Opposite Parties.

Counsel for the Parties:-

For the Complainant :- Sri A.B.Sahu, Advocate with associates.

For the Opposite Parties  :-      Sri M.Bhoi, 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.30/04/2024.                                 -: 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 the bonafide consumer of the Opposite Parites and for his health insurance has insured vide policy No. P/191214/01/2022/002675 has paid premium of ₹16,980/-(Rupees sixteen thousand nine hundred eighty)only on Dt. 22-09-2021 to the Opposite Parties. In the said policy namely Family Health Optima Insurance Plan the Complainant and his family are insured. On Dt.23-09-2021, the Complainant became ill and was admitted to Vikash Multispeciality Hospital for treatment and where the Complainant was detected with Heart Attack. The Complainant had to undergo heart operation and after treatment the Complainant placed the insurance claim before the Opposite Parties. But, the Opposite Parties instead of settling the claim have deferred the matter in different plea. The Complainant for settlement of the insurance claim from the Opposite Parties have sustained harassment and mental agony including monetary loss for which the Complaint was filed by the Complainant before this Commission praying that the Opposite Parties be directed to pay ₹4,27,320/-(Rupees four lakh twenty seven thousand three hundred twenty)only towards claim and compensation.

2)         The case of the Opposite Parties is that the Opposite Party No.1(one) and No.2(two) have jointly filed its version and submitted that the Complainant opted for Family Health Optima Insurance 2021 which included self, Mrs. Arundhati Barik (spouse) Pratikhaya Priyadarshine Barik and Pratik Barik (dependent children) for floater sum insured of ₹3,00,000/-(Rupees three lakh)only vide policy No. P/191214/01/2021/ 002004 for the period 17-08-2020 to 16-08-2021 and subsequently the policy was renewed by Policy No. P/191214/01/2022/002675 for the period 22-09-2021 13:17 hours to 21-09-2022 midnight. In between the Policy there is a breakin of period from 17-08-2021 to 22-09-2021, 13:16 hours, but the Complainant insured the Policy on 22-09-2021 at 13:17 hours. The Opposite Parties further submitted that the Complainant was suffering from diseases like type 2 diabetes mellitus, hypertension, coronary artery disease with acute coronary syndrome prior to validity of insured period and the OPD prescription and initial ascertain admission from dated 22-09-2021 as the Complainant complaint acute pain in left side of his chest at 9:30 AM and blood test, ECG was conducted prior to the renewal time of the policy. The Opposite Parties has denied the claim for cashless facility for the reason that the policy was renewed after the braken period from 17-08-2021 to 22-09-2021, 1:16 PM. There is no negligence and deficiency in service on the part of the Opposite Parties and the case to be dismissed against the Opposite Parties.

3)         Perused the oral submissions and written arguments documents filed by the Complainant and the Opposite Parties,  following issues are framed.

Issues

1. Whether the Opposite Parties are deficient in its service ?           
2. What relief the Complainant is entitled for ?

Issue No.1(one)

4)         It is an admitted fact that the Complainant was insured with the Opposite Parties and the Policy was renewed bearing No. P/191214/01/2022/002675 valid from 22-09-2021 13:17 to midnight of 21-09-2022. In the said policy it was specifically mentioned that the Complainant has NO PED declared. The Opposite Parties have submitted that on dt. 22-09-2021 as the Complainant complained acute pain in left side of his chest at 9:30 AM prior to the renewal of the policy the Complainant has undergone many medical tests but the Opposite Parites have not filed any report, further the medical documents filed by the Complainant reflects that the Complainant has gone to the hospital on 23-09-2021 at 7:32 AM. The policy was renewed and at the time of renewal it is the duty of the Opposite Parties to examine the Policy holder but the Opposite Parties failed to exercise their duty. In the present case there is no documentary evidence filed by the Opposite Parties that the Complainant was diagnosed with pre-existiting disease. The Complainant has submitted medical bills regarding the treatment dt. 23-09-2021. Non settlement of claim when the insurance is valid amounts to deficiency in service on the part of the Opposite Parties.

Issue No.2(two)

5)         The Complainant is entitled for the relief claimed.

            Accordingly 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 ₹2,27,320.17/-(Rupees two lakh twenty seven thousand three hundred twenty and seventeen paise)only towards medical expenses along with ₹30,000/-(Rupees thirty thousand)only for deficiency in service and ₹10,000/-(Rupees ten thousand)only towards litigation expenses to the Complainant within 30(thirty) days of this Order, failing which, the 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.30/04/2024 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.