Date of filing:- 12/05/2023.

Date of Order:-18/06/2024.

DISTRICT CONSUMER DISPUTE REDRESSAL COMMISSION

B A R G A R H (ODISHA).

Consumer Complaint No. 61 of  2023.

            Dr. Durbadala Meher, S/o late Dolamani Meher, aged about 62(sixty two) years, Resident of Badriprasad Apartment, B. Block Q No. 407, Bargarh, Ps/Tahasil/Dist. Bargarh.                                                             .....            .....     .....         Complainant.

-: V e r s u s :-

1. The General Managers, Star Health & Allied Insurance Company Ltd., Represent through its Branch Manager, First floor, 24SCR, Bapuji Nagar, Janpath, Bhubaneswar, Pin-751009.
2. Manager, Star Health & Allied Insurance Company Ltd (Branch), 2^nd Floor Quality Mansion Nayapara, Sambalpur-768001.
3. Star Health & Allied Insurance Company ltd through its CEO No. 15, Sri Balaji Complex, 1^st Floor Whites Lane Roy Apettah Chhenai-600014.

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

Counsel for the Parties:-

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

For the Opposite Parties  :-                  Sri M.Bhoi, Advocate with associates.

                                                            -: 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.18/06/2024.                                 -: 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 purchased a health policy for him and his wife jointly on 20-10-2013 bearing Policy No. 11230200017205 and paid the yearly premium as fixed by the Opposite Parties. The policy was renewing every year since then without lapses. The policy was last renewed on 19-10-2022 by paying the annual premium of ₹ 41,813/-(Rupees forty one thousand eight hundred thirteen)only and it is valid upto 20-10-2023. The Complainant suffered for kidney disease for which he was admitted in Apollo Hospital on 13-01-2018 and discharged on 22-01-2018. The Complainant as a employee the total expenditure was reimbursed by the Government for which he did not claim from the Star Health & Allied Insurance Company Ltd. Unfortunately all on a sudden on 08-03-2023 the Complainant felt pain in his chest and he was admitted to Vikash Hospital, Sambalpur for treatment, where in it was detected heart disease and Angioplasty was done in his RCA by the Dr. Bikramdity Padhi. Thereafter necessary treatment was done there by the doctors to save his life. Due to timely treatment the life of the Complainant was saved. The Complainant is entitled for the insurance claim as the insurance policy was intact by then. As per term and condition the policy was processed for cashless treatment. But the company asked the Complainant on dated 13-03-2023 to submit the paper relating his rental translation, which the Complainant could not submit at that time. For that reason cashless facility was declined with instruction to submit the claim for reimbursement again. The Complainant paid the total amount of ₹ 1,85,000/-(Rupees one lakh eighty five thousand)only from his own pocket to get discharge certificate from the Vikash Hospital, Sambalpur. On 20-03-2023 the Complainant once again claim before the Opposite Parties and also furnished all relevant documents required by the Opposite Parties. Further on the requirement of the Opposite Parties the Complainant submitted KYC/bank details in a cancelled cheque. But instate of setting the claim of the Complainant the Opposite Parties have deferred the matter on different plea. The conduct and acts of the Opposite Parties towards the Complainant amount to negligence and deficiency of rendering service to a consumer. Hence the Complainant filed this case before this Commission.

2)         The case of the Opposite Parties is that the Opposite Parties filed their version. The Opposite Parties admitted that the insured Dr. Durbadala Meher and his wife have taken policy jointly in October-2017 bearing Policy No. 11230200017205 and paid the yearly premium amount. The Opposite Parties submitted that as per discharge summary from Apollo Hospitals, Bhubaneswar for the period of hospitalization dated from 13-01-2018 to 22-01-2018, it is observed that the patient/insured was already diagnosed with CKD which is prior to policy inception and also had undergone renal transplant on 16-01-018 which is during the hospitalization at Apollo Hospital. The insured had not disclosed the ailments during the time of policy inception on 21-10-2017 and got  admitted at Apollo Hospital just after 2(two) months of policy inception. The insured had not disclosed the medical history/health details of the insured person in the proposal form which amounts to misrepresentation/non disclosure of material facts. As per condition  No.1(one) of the policy issued if there is any misrepresentation/non-disclosure of material facts whether by the insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim.

3)         Perused the complaint petition, version and documents filed by the Parties and following issues are framed :-

Issues

1. Whether the Opposite Parties are deficient in service ?
2. Whether the Complainant is entitled to get relief ?

Issue No.1(one)

4)         It is the admitted fact that the Policy No. 11230200017205 was issued by the Opposite Parties Star Health and Allied Insurance Company ltd. It is also admitted fact that the Complainant admitted in Vikash Hospital, Sambalpur on 08-03-2023 and discharged on 10-03-2023. The Complainant filed the receipt of Vikash Hospital dated 10-03-2023 of ₹ 1,85,000/-(Rupees one lakh eighty five thousand)only. The Complainant paid the entire amount and discharged from hospital. When the Complainant lodged claim after discharged from hospital, the Opposite Parties denied the claim of the Complainant on the ground that misrepresentation/non-disclosure of fact. The Opposite Parties filed the repudiation letter and documents. But it is the duty of the Opposite Parties to settle the claim when the policy is admitted and during the currency of the policy the Complainant/insured admitted in the hospital. The Complainant produced bill of the hospital also. But the Complainant in order to avoid payment is taking plea. The Opposite Parties are deficient in service for non settlement of claim of the Complainant. The issue is answered accordingly.

Issue No.2(two)

5)         For deficiency in service of the Opposite Parties 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

6)         The Complaint is allowed on contest against the Opposite Parties. The Opposite Parties are jointly and severally directed to pay ₹ 1,85,000/-(Rupees one lakh eighty five thousand)only to the Complainant within one month from the date of this Order. Further the Opposite Parties are directed to pay ₹ 40,000/-(Rupees forty thousand)only compensation for deficiency in service and ₹ 10,000/-(Rupees ten thousand)only for litigation expenses to the Complainant. Failing which the entire amount will carry 12%(twelve percent) interest per annum till realization.

            Order pronounced in the open court on 18^th day of June 2024.

                        Supply free copies to the Parties.

                                                                                             Typed to my dictation

                                                                                              and corrected by me.

                                    I agree,                                           ( Smt.Jigeesha Mishra)

                                                                                                    P r e s i d e n t.

                       (Smt. Anju Agrawal)

                             M e m b e r(w).