Date of filing:-   05/07/2021.                                                                         Date of Order:-04/09/2023.

DISTRICT CONSUMER DISPUTE REDRESSAL COMMISSION,

B A R G A R H.

Consumer Complaint No.   35  of 2021.

Kanchan Kumar Chakrabarty, S/o. Late Binay Chakrabarty resident of College Road W. No.12, P.s. Dist. Bargarh.                                                                                                                                                       Complainant.

V e r s u s

1. The Branch Manager LIC of India  Sambalpur through Branch Manager Bargarh, Branch, Bargarh Po/Ps/Dist. Bargarh.
2.  MEDI ASSIST INSURANCE TPA PVT. LTD 4TH FLOOR AARPEE CHAMBERS OFF ANDHERI KURLA ROAD INDUSTRIAL ESTATE, MAROL COOPERATIVE NEXT TO TIMES SQUARE, SHAGBAUG, MUMBAI PIN 400056.
3.  New Assurance Company Ltd, Sambalpur.                                                                                                                                                                                                                     

                                                                                                                  Opposite Parties.                         

Counsel for the Parties:-

For the Complainant :-                :- Sri J.K. Padhan, Advocate with Associates.

For the Opposite Party No.1 :-    :- Sri A.B. Sahu, Advocate with Associates.

For the Opposite Party No.2 :-    :- Exparte.

For the Opposite Party No.3 :-    :- Sri Ashok Kumar Dash, Advocate.

                                          -: 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.04/09/2023.                          -: J   U  D   G  E  M  E  N  T:-

Presented by Smt. Jigeesha Mishra, President :-

1. The case of the Complainant is that  the Complainant is an agent of Opposite Party No.1 and the policy holder with the Opposite Party No.3 having its policy No. 12030034180400000011 and Opposite Party No.2 is a third party administrator. The petitioner suddenly got some problem in his health and during his treatment in the month of August he was diagnosed as Renal failure patient (CKD) and was admitted in Shree Balaji Institute of Science Pvt.Ltd. Raipur for  his treatment on 09/01/2019 to 22/01/2019. During that procedure of Renal transplantation was done. The Petitioner spent Rs. 19,00,000/-(Rupees nineteen lakh)only for the purpose of treatment. The petitioner after his treatment raised his claim before Opposite Party No.3 through Opposite party No.2. Inspite of several request by the Complainant the claim was not settled. Hence the Complainant filed this case before this Commission.
2. The case of the Opposite parties is that the Opposite party No.1 and Opposite Party No.3 filed their version Opposite Party No.2 did not file version. Sufficient Opportunity has been given to the Opposite party No.2. But Opposite Party No.2 did not turn up. Hence Opposite party No.2 is set exparte.

Opposite Party No.1 submitted that the Complainant has subscribed to the group medical policy i.e. master policyNo. 12030034180400000011. The Opposite Party No.1 further submitted that the Opposite Party No.1 deducted premium from the Commission of the Complainant and remitted to the New India Insurance Company. The Opposite Party No.1 has no responsibility in connection with the matter of insurance of the Complainant. Hence the Opposite party No.1has no deficiency and prayed for dismissal of the case.

Opposite party No.3 admitted that the Complainant Kanchan Kumar Chakrabarty is insured with Opposite Party No.3 under Flexi Floater Group Mediclaim policy bearing No. 12030034180400000011 which was valid from 01/09/2018 to 31/08/2019 for a sum assured of Rs. 1,50,000/-(Rupees one lakh fifty thousand)only. The Opposite party No.3 submitted that the Complainant was suffering from the disease before the Commencement of the insurance policy. The Complainant has not disclosed about the preexisting disease. The insured has intentionally hidden the material fact to the insurance company which is violation of policy conditions. Hence the Complainant is not entitled for any compensation. Further the Opposite Party No.2. Served notices to the Complainant dated 09/06/2019, 19/06/2019 and 27/06/2019 to provide documents. But inspite of several remainders the Complainant failed to provide the documents which are very much essential in settling the claim. In absence of document the Opposite Party No.3 could not settle the claim of the Complainant. Hence there is no deficiency on the part of the Opposite Party No.3 and Opposite No.3 prayed for dismissal of the case.

3. Perused the Complaint petition, version and documents filed by the parties and  following issues are framed:-
4.  

1.Whether the Opposite Parties are deficient in  service ?

2. What relief the Complainant is entitled to get ?

Issue No.1.

      It is admitted fact that the policy No. 12030034180400000011 was valid from 01/09/2018 to 31/08/2019 and the Complainant was the insured in that policy for a sum assured value of Rs. 1,50,000/-(Rupees one lakh fifty thousand)only. The Complainant admitted in Shree Balaji Institute of Science Pvt.Ltd, Raipur for treatment from 09/01/2019 to 21/01/2019 within the validity period of the insurance policy. As per document filed by the Complainant on 22/05/2019 the Opposite Party No.1 has sent all the document including original claim form, all the bills, Adhar card etc. But the Opposite Party No.3 is taking plea that the Complainant has not submitted documents. Hence the plea taken by Opposite Party No.3 is not acceptable. Again Opposite Party No.3 submitted that the Complainant has not disclosed the pre existing desease. It is the duty of the insurance company to conduct medical examination at the time of giving insurance policy. In order to avoid payment the Opposite Party No.3 is taking plea. Non settlement of claim of the Complainant amounts to deficiency in service on the part of the Opposite Party No.3.

      The issue is answered accordingly.

Issue No.2.

      For deficiency in service of the Opposite Party No.3 the Complainant is entitled to get relief. The issue is answered accordingly

      As per supra discussion the following order is passed.

O R D E R

The Complaint is allowed on contest against the Opposite Party No.3 and dismissed against Opposite Party No.1 and Opposite Party No.2. The Opposite Party No.3 is directed to pay Rs. 1,50,000/-(Rupees one lakh fifty thousand)only to the Complainant within one month from this order. Further the Opposite Party No.3 is directed  to pay Rs. 25,000/-(Rupees twenty five thousand)only compensation for harassment and mental agony and Rs. 5,000/-(Rupees five thousand)only for litigation expenses to the Complainant. Failing which the entire amount will carry 12% interest P.A. till realization.

Order pronounced in the open court on this  4^th     day of  September 2023.

            Supply free copies to the parties. 

                                                                                      Typed to my dictation

                                                                                      and corrected by me.                                                                                           

                   I  agree/-                                                                 

       ( Smt. Anju Agrawal )                                                                  ( Jigeesha Mishra )

              Dt.04/09/2023                                                                            Dt.04/09/2023

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