Adv. For the Complainant         : -    A. Sahu and Other

        Adv. For O.P. No. 1, 2, & 3        :-   Radha Kanta Mahakur

       Adv. For O.P. No.4                       :-  Pratap Chandra Sahoo

       Adv. For O.P. No.5                       : No

       Date  of filing of the Case           :- 24.02.2021

        Date of Order                               :- 03.06.2024

 JUDGMENT

The Fact of the case in nutshell –

1. The complainant had opened Family Health Optima insurance – 2017 policy vide policy No. P/191214/01/2019/002577 with renewal endorsement no. P/191214/01/2020/003978 paying an amount of Rs.17, 009/- which valid from 29/02/2020 to 28/02/2021 through OP No.4 with OP 1, 2 and 3 on dated 21/02/2019. In due course of time the complainant victimized of covid-19 (+) diagonised as positive admitted to Vikash Multi Speciality Hospital, Bargarh on dated 22/09/2020 to 28/09/2020 and spent Rs. 1,58,000/- as Medical expenses from his own pocket  this matter was intimated to the OPS for reimbursement of the said amount but was issued with a rejection letter of insurance claim on dt.17/12/2020 and the Ops acted a deaf year towards the complainant, Hence this case.

2. To substantiate his case the complainant relied on the following documents.

1. The Photo copy of policy certificate vide policy no. P/191240/01/2019/0057 and the policy bond.
2. Photo copy of the rejection letter dated 17/11/2020.
3. Photo copy of invoice expenditure slip of Vikash Multi Speciality Hospital.
4. Photo copy of other medical related documents.

3. Having  gone through the complaint it’s accompanied documents and on hearing the complainant prima facie it seemed to be a genuine case hence admitted and in response they appeared through their councel and unable tofile any written version in the statutory period . sufficient opportunity has been given to the Ops but due to non filing of the version OP No.2 set ex-parte on dated 13/06/2022 Op No. 1 and 3 set ex-parte on dated 13/10/2022 and Op No. 5 set ex-parte on dated 11/01/2024 only OP no.4 the agent appeared on dated 19/07/2022 and admitted that he was a bonafide agent of M/s Star Health and Allied insurance company and stated his duty came to an end after sales of the policy product it is OP no. 1,2,3who are liable for repudiation of the claim. OP no. 4 prayed for exempted from any claim / dispute liabilities, as such he should be deleted from the Joinder of necessary party.

4. While going to the merit of the case it is found that the complainant opened a policy vide no. P/19214/01/2019/00257 valid from 21/02/2019 to the midnight of 20/2/2020 and also the policy bond in support to the policy certificate which is found on the record. In the policy bond it is clearly stated the empanel list of hospitals in Odisha which cover the mediclaim. If the policy holder treated on that particular empanel hospitals only. where it mention  the name of Sai Multi Speciality hospital Bargarh, Kishori Nurshing Home and Behera Nurshing Home, Bargarh exclude the name of Vikash Multi Speciality Hospital Bargarh, But the complainant was medically treated at Vikash Multi Speciality Hospital, Bargarh which found from the medical documents on the record.

However the complainant was treated at Vikash Multi Speciality Hospital from the documents filed by the complainant found that the complainant was found covid-19 positive and made an expenditure of Rs.1,58,000/- from his own pocket and claim before the OPS for reimbursement of the same but the Ops in their rejection letter dated 17/11/2020 stated the policy no. vide P/19124/01/220/003978 bearing claim intimation no. CLI/2021/19214/0347098 with a cause “ even after remindersyou have not sent us the above documents we therefore presume that you are not interested in preferring the claim and the same is rejected”.

Here in the instant case the complainant has not filed any documents such as the renewal policy certificate or the renewal policy bond, which is a important and vital document which help the commission to adjudicate the matter with a reasonable manner. As such the allegation made in the complaint petition is lacking the support of document which have evidentiary value. It is settled principle of law that the parties are binded by their pleading with support by the documentary evidence on which they relied on. Due to the non filing of the important document this commission unable to adjudicate the case in a reasonable member.

Hence the case is dismissed for lacking valuable document to support the allegation.

No award as to cost.

PRONOUNCED IN THE OPEN COMMISSION TODAY I.E DATED  03^th   DAY OF  June’2024