Date of filing:- 20/01/2023.

Date of Order:-25/06/2024.

DISTRICT CONSUMER DISPUTE REDRESSAL COMMISSION

B A R G A R H (ODISHA).

Consumer Complaint No. 09 of  2023.

            Kanan Prasad Mishra, S/o Late Kedareswar Mishra, aged about 53(fifty three) years, Occupation- Cultivation & Business, R/o Bheden, Po/Ps/Tahasil- Bheden, Dist. Bargarh (Odisha).                                                          .....       .....     .....         Complainant.

-: V e r s u s :-

1. The Manager, CARE Health Insurance ltd., 229 A Saheed Nagar, Bhubaneswar-751007 (Odisha).
2. The General Manager, CARE Health Insurance Ltd., Unit No. 604-607, 6^th Floor, Tower C, Unitech Cyber Part, Sector 39, Gurugaon-122001 (Harayana).

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

Counsel for the Parties:-

For the Complainant :-            Sri M.K.Satpathy, Advocate with associates.

For the Opposite Parties:-                    Sri A.K.Dash, 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.25/06/2024.                                 -: 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 is a bonafide consumer of the Health Insurance Policy of the Opposite Parties vide Policy No. 34554857 which was valid from 05-10-2021 to 04-10-2022. The Complainant has been paying the requisite premium regularly. The Complainant suffered with sudden heart attack on 07-10-2021 and treated in VSS Medical College Hospital, Burla and subsequently shifted to Care Hospital, Bhubaneswar and treated by specialized doctors so also angioplasty was conducted. As the insurance policy of the Complainant was intact, the Complainant has placed the insurance claim before the Opposite Parties. The Complainant has also furnished relevant documents as desired by them time to time on their direction. Instead of settling the claim of the Complainant, they have deferred the matter on different plea. Finally they have denied the claim on the ground that four years waiting period is applicable for pre-existing disease and the case of the Complainant related to diabetes complications. Such conduct of the Opposite Parties amounts to negligence and deficiency in service. Hence the Complainant filed this case before this Commission.

2)         The case of the Opposite Parties is that the Opposite Party No.1(one) and  No.2(two) Care Health Insurance limited filed their version. The Opposite Parties admitted that the insurance company issued an insurance policy under the plan namely “POS CARE” bearing Policy No. 34554857 providing policy coverage to Complainant Mr. Kanan Prasad Mishra, Complainant's spouse Mrs Gitanjali Mishra and Complainant's daughter Krutika Mishra and the policy was from 05-10-2021 to 04-10-2022 for a sum insured upto ₹ 5,00,000/-(Rupees five lakh)only. The Opposite Parties submitted that a cashless request (AL No. 80619869) was received from the Care Hospital on behalf of the Complainant for his hospitalization on 23-11-2021. As per the pre-authorization form the Complainant diagnosed with CAD IWMI. After receipt of the cashless request a query dated 23-11-2021 was raised to the hospital. Upon perusal of the submitted documents, it was observed that had undergone the treatment for Chonic Ischemic Heart Disease. The insured had declared PED of Diabetes for himself in the proposal form at the time of issuance of policy. As per clause 4.1 (a) (i) (a) there is a standard exclusion where waiting period is 48(forty eight) consecutive months for covering the expenses related to pre existing disease. The present claim is filed for the Chronic Ischemic Heart Disease which is the direct complication of insured PED of Diabetes and since the claim is filed within 48(forty eight) months of continuous coverage, therefore the same will not be admissible as per policy terms and conditions. Hence the insurance company has repudiated the cashless request and intimated to the treating hospital vide denial letter dated 24-11-2021. The Opposite Parties have no any deficiency.

3)         Perused the complaint petition, versions 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)         The policy is admitted and during the currency of the policy the insured admitted in the hospital. But the Opposite Parties repudiated the claim of the Complainant on the ground that waiting period for pre-existing disease is 48(forty eight) months. As the Complainant lodged claim within 48(forty eight) months and the Complainant was suffering from diabetes since long the insurance company repudiated the claim. It is the only submission of the insurance company. When the policy is admitted and the insurance company had taken premium for health policy and the policy was valid, it was the duty of the Opposite Parties to settle the claim. But the Opposite Parties have repudiated the claim of the Complainant which amounts to deficiency in service on the part of the Opposite Parties. 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. As per the prayer of the Complainant the insurance claim is ₹ 6,00,000/-(Rupees six lakh)only. But the Opposite Parties submitted that the sum insured is ₹ 5,00,000/-(Rupees five lakh)only. So we allowed  ₹ 5,00,000/-(Rupees five lakh)only the sum insured amount of the policy. 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. The Opposite Parties are jointly and severally directed to pay ₹ 5,00,000/-(Rupees five lakh)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 lakh)only compensation for deficiency in service and ₹ 10,000/-(Rupees ten thousand)only for litigation expenses to the Complainant. Failing which the entire amount shall carry 12%(twelve percent) interest per annum till realization.

            Order pronounced in the open court on 25^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).