Adv. For the Complainant   : -   Bikash Chandra Pradhan and Goura Chandra            

                                                   Naik

Adv. For O.Ps                        :-   Sumit Ram Bharadwaj

Date  of filing of the Case     :-     02.06.2023

Date of Order                         :-    19.12.2023

JUDGMENT

The fact of the case in nut shell:-

1. The complainant insured a madi – claim policy in the year 2013 with NIVA BUPA HEALTH  INSURANCE Company ( Previously Know as MAX BUPA HEALTH INSURANCE). His policy was valid from the year 2013 to 11.01.2022. Before expiry of the previous policy  of 2021/22 the complainant portability the policy with one STAR HEALTH ALLIED

INSURANCE COMPANY. With the consolation of an agent of starHealthAllied Insurance namely Jagannath Meher after finalization the complainant deposited a sum of Rs.49,100/- as premium , where the sum assured was 10 lakh which effect from 12.01.2022 to midnight of 11.01.2023. within the coverage period of the policy there was a tumour developed on the right cheek on the face of the complainant. Which was detected by the Dr. Govt. hospital Patnagarh which need operation. The complainant for better treatment moved to Samaleswari Nurshing Home, Burla and got operated the same on dt.22.09.2022 with a medical expenditure of Rs.30,000/- for better result the biopsy test was conducted by Patholab Mangalabagcuttack. Which came with a finding of Tumour type MUCOEPIDERMOID CARCINOMA of MINOR SALIVARY GLAND, which received by the complainant on dt 27.09.22 and for better treatment the complainant moved to Bombay for PET scan and spent Rs.50,000/-as medical expenses. Again the complainant on the advice of the oncologist AIMS for radiation. The complainant admitted himself at UtKal Health Care Pvt. Ltd. Bhubaneswar on dt.07.11.2022 and paid a bill to the hospital a sum of Rs.2,60,000/- and Rs.27,518/- and Rs.13,112/- as medicine cost. and discharged from the hospital on dt 29.12.2022. The said hospital is one of the authorized hospital of star Health Allied Insurance Company. The complainant sent information through the hospital to the Insurance company for cash less benefit treatment but the insurer repudiate the contract on the ground that the complainant has been suffering from CARCINOMA BUCCAL MUSA since 2007 which is prior to inception of the first policy which comes under suppression and concealment of the material fact.

           The Ops knowing full well about the facts. Intentionally harassed the complainant . Hence this case.

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

1. Portability policy certificate vide no P/619006/01/2022/00079 issued by star Health and Allied Insurance Co. Ltd.
2. Policy certificate vide no. 310689202106 by MAX BUPA Health Insurance.
3. Rejection authorization for cash less treatment on dt.11.11.2022 issued by the insurance to the Hospital.
4. Admission and discharge summery given by Utkal Hospital pvt. Ltd. dt.29.12.2012 and other medical related document.

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 notice to the Ops were served and in response the OPs did not appeared sufficient opportunities has been given to the OPS for filing of the written version with in the statutory period prescribed by the consumer protection Act 2019. As such the Ops failed to establish their credential with in the time bound and set exparte against the complainant on dt.30.10.2023.

Consumer commission has no Jurisdiction no power for permissibility to file the W.S. at a belated stage or to accept the W.S beyond the period of 45 days held kerala SCDRC in senior BM. National Insurance Co. Ltd. Vrs. Dinjayan and other F.A. 199 of 2021 arising out of CC.213/2018 of District Kollam decided on 26.09.2023. Likewise in J.J. Marehant case (Supra) having the same view in NIA vrs. Hilli Multipurpose Cold storage Pvt. Ltd. 2020 5 Scc 757.

As because the Ops set exparte this commission presumed that the allegations made by the complainant on the complaint petition which the Ops admitted as true hence the complainant is entitled for relief with following direction.

ORDER

1. The Ops are directed to pay a sum of Rs.3,40,000/-@9% interest per annum towards medical expenditure from the date of filing till the date of order, and Rs.25,000/- towards mental agony and Rs.5,000/- towards litigation expenses within one month from the date of order failing which the entire amount shall be paid by the OPS@12% interest per annum from the date of filing of the case till realization.

2. Further the OPS are directed to continue the policy  till the default in payment of the premium by the Complainant.

No award as to cost.

         PRONOUNCED IN THE OPEN COMMISSION TODAY I.E   DATED  19^th  

           DAY OF  December’2023.