DIST.CONSUMER DISPUTES REDRESSAL COMMISSION, KHURDA, BHUBANESWAR:

                                                -ooOoo-

C.C.CASE NO. 103/ 2020

Madhu Sudan Panda, aged about 61 years,

S/o Bhagaban Panda,Plot No.HIG-A-1,

Baramunda Housing Board Colony,

Baramunda, PS- Khandagiri,

Bhubaneswar, Dist - Khurda

….     Complainant             

-Vrs.-

1.       HERITAGE HEALTH INSURANCE TPA PVT. LTD.,

          Nicco House, 5^th Floor, 2 Hare Street,

          Kolkata – 700 001, through its Managing Director.

2.       Regional Manager, United India Insurance Company Ltd.,

          At – 1^st Floor Orissa Co-operative Housing Co.Ltd., Door No.

          Block No.1, Unit – III (Besides Ram Mandir, Bhubaneswar)

          Dist – Khurda

3.       United India Insurance Company Ltd.,

          At – 24, Whites Road, Chennai – 600014, Tamilnadu,

Through its Managing Director.

.

….     Opp. Parties 

For the complainant      :         Sri K.C.Prusty (Adv.)

For the O.Ps 2 & 3        :         Mr. B.R.Mishra & Associates  (Adv.)

For the OP.1                            :         Exparte

DATE OF FILING         :         13/07/2020

DATE OF ORDER        :         03/04/2023

ORDER

K.C.RATH, PRESIDENT

1.       This is an application U/s 12 of the C.P.Act, 1986.

2.       The complainant’s case in brief is that, Madhu Sudan Panda was an employee of the United Bank of India.  The Untied Bank of India launched one Group Health Insurance Policy  for its employees and insured its employees with the OPs under  Employee Group Health Insurance Policy. In that policy, not only the employee but the wife & children of the employee were all covered under the policy. On 10/09/2017, the son of the complainant / employee namely  Mahaprasad Panda was admitted to AMRI hospital  and was under treatment till 13/09/2017 and was discharged thereafter. He lodged claim before the OPs but the OPs repudiated the claim on the ground that the required documents were not submitted with the OPs within the stipulated  time. Hence this complaint.

3.       On the other hand,  the  OPs 2 & 3  filed written version  admitting the existence of Group Health Insurance Policy but deny  the claim as the relevant documents were not submitted  to the OPs within three months from the date of the discharge. As the insured  violated the policy condition, the claim was repudiated.  The complaint,  being devoid of  merit,  is liable to be dismissed with cost.

The OP.1  did not appear in the case, as such it was set exparte.

4        Perused the materials on record. The complainant, Madhu Sudan Panda was  the employee and was the holder of the Health card. Under that Group Health Insurance Policy, his wife and his son were also covered. Health card was also issued in the name of his son,  Mahaprasad Panda. Discharge summary issued by AMRI hospital shows that,  Mahaprasad Panda was admitted in the hospital  on 10/09/2017 and was discharged on 13/09/2017. He was admitted in the hospital for sudden pain in right side scrotum. The total expenditure incurred for the treatment of Mahaprasad Panda, was Rs.94,989.69. The mere fact that the documents were not submitted to the OPs within the stipulated time, is not sufficient to deny the claim of the insured. The OPs have taken premium for the purpose to make themselves  liable  under such contingency.  The denial  to settle the claim in favour of the claimant, is not justified  in the eye of law. As such, the complaint bears  merit.  Hence it is ordered.

ORDER

The complaint is  allowed  exparte against the OP.1 and allowed on contest against the OPs 2 & 3.  The OPs are    jointly & severally liable to pay Rs.94,989.69/- (Rupees ninety-four thousand nine hundred  eighty-nine and sixty-nine paisa ) only  to the complainant.  Besides, the OPs  are  further liable to pay  compensation of Rs.20,000/-   (Rupees twenty  thousand) only  towards mental agony suffered by the complainant and a  sum of Rs.2000/-  (Rupees two thousand) only towards litigation expenses.  The order be complied with by the OPs  jointly & severally  within a period of  thirty days from the date of communication of this order,   failing which the complainant will be  at liberty to execute the order  against the OPs   in accordance with law.

The order is pronounced on this day the  3^rd April,  2023  under the seal & signature of the President and Member (W) of the Commission.

                                                                                      (K.C.RATH)    

                                                                                        PRESIDENT

 Dictated & corrected by me

          President                                                                                    

I agree                                                                            

(S.Tripathy)                                                                           

Member (W)                                                                                                                                                 

Transcribed by Smt. M.Kanungo, Sr.Steno