Date of filing:-03/09/2013.
Date of Order:-21/09/2016.
DISTRICT CONSUMER DISPUTE REDRESSAL FORUM (COURT)
B A R G A R H
Consumer Complaint No. 43 of 2013
Kamal Kumar Banka, aged about years, son of Jugal Kishor Banka C/o Banka Hard Ware Store, Ward No-7(seven), Main Road, Bargarh Po/Ps/Dist:- Bargarh
..... ..... Complainant.
Birla Sunlife Insurance Private Limited. At- Regd. Office one India bull Centre Tower No. 1, 15th,16th floor Zupitor Mill compound 841 Senapati Bapat Marg, Eliplinestin Road, Mumbai- 400013.
Birla Sunlife Insurance Company, Private Limited, represented through the Branch Manager of the Company 1st floor near Gurudwara, At/Po/Ps/ Dist- Bargarh.
..... ..... ..... Opposite Parties.
Counsel for the Parties.
For the Complainant:- Sri S.S. Shukla, Advocate with other Advocates.
For the Opposite Parties:- Sri S. Srivastava, Advocate with other Advocates.
-: P R E S E N T :-
Sri Krishna Prasad Mishra ..... ..... ..... ..... ..... P r e s i d e n t.
Sri Pradeep Kumar Dash ..... ..... ..... ..... ..... M e m b e r.
Dt. 21/09/2016 -: J U D G E M E N T :-
Presented by Sri K.P. Mishra, President:-
Briefly the case of the Complainant:-
The Complainant being persuaded by one Narayani Rajesh Kumar, Business Advisor of the Opposite Parties, took one policy Opposite Party No.1(one) from the local office of the Opposite Party No.2(two) for his life insurance and health care benefit bearing policy No.005333992, wherein the Complainant was assured with a Sum of Rs. 7,00,000/- (Rupees seven lakhs)only in case of the accidental death and Rs. 2,50,000/-(Rupees two lakhs fifty thousand)only for hospital care benefit for any diseases and for that the Complainant paid an amount of Rs. 8,300/-(Rupees eight thousand three hundred)only as yearly premium to the Opposite Party No.1(one) through Opposite Party No.2(two). On Dt. 20/01/2012 against the said amount, policy bond was issued by the Opposite Party No.2(two) on behalf of the Opposite Party No.1(one) for a period of 30(thirty) years commencing from Dt.20/01/2012 to Dt.20/01/2042. And accordingly the Complainant paid the second premium of Rs.8,300/-(Rupees eight thousand three hundred)only to the Opposite Party No.2(two) on date 04/02/2013 vide receipt No. 40614714 issued by the Opposite Party No.2(two) on behalf of the Opposite Party No.1(one).
Further the case of the Complainant is that, during the subsistence of the said policy suddenly in the month of July- 2012, he fell in ill and both of his eyes got effected by a diseases namely High Myopia and as such he was shifted to a private hospital of Nagpur, Maharastra namely Evista care centre wherein he was admitted on Dt.10/07/2012 under the treatment of Dr. Sanjaya Jaiswal and in the process he had undergone an operation which is known as B.E. Lasik Surgery and was discharged from the said hospital on Dt.12/07/2012 at 6.30. p.m. And in such treatment an amount of Rs. 43,447/-(Rupees forty three thousand four hundred forty seven)only besides other expenditure was incurred by the Complainant. So after recovery from his such illness preferred claim before the Opposite Parties as of his legitimate claim as per insurance policy of the Opposite Parties and sent all relevant documents in support of his illness, treatment and aforesaid health care policy claim through courier service vide receipt No. 133101451 on date 14/07/2012 but to no effect. Thereafter the Complainant sent a notice through regd. post on Dt. 07/12/2012 to which the Opposite Parties responded and asked for some more documents of the said hospital relating to the treatment and accordingly again the Complainant sent all the relevant documents which are in his possession and also requested the Opposite Parties to verify some documents such as first consultation papers with findings with subsequent consultation papers and all investigation report pertaining to exact date of diagnosis and treatment and indoor case papers for treatment during admission in hospital. Which he was asked for by the Opposite Parties in their letter Dt. 12/12/2012 because those documents were not supplied to him by the said concerned hospital as a matter of principle of the hospital.
But again to the harassment of the Complainant the Opposite Parties demanded repeatedly for those said documents to avoid for making payment of his claim as per the case of the Complainant. As such seeing no other alternative the Complainant sent a notice through Insurance Ombudsman Bhubaneswar on Dt. 06/03/2013 to the Opposite Parties but to no effect and again on Dt.16/08/2013 approached the Opposite Parties No.2(two) to enquirer about the claim and settle the same but to no effect.
The claim has been denied by the Opposite Parties several time even after payment of the due premium on the Complainant in time and following all the formalities as per the term and condition of the policy of the Opposite Parties and suddenly to the utter surprise of the Complainant the Opposite Party No.1(one) sent a cheque of an amount of Rs. 2,000/-(Rupees two thousand)only with out any semblance of any claim for such an amount of the same which caused a serious mental harassment and mental agony to the Complainant, although he has claimed for an amount of Rs.50,000/-(Rupees fifty thousand)only in total hence as per him the cause of action for the case arosed on Dt.18/01/2012, when the premium was paid & on Dt. 09/07/2012, when he fell in ill, and he was admitted in the hospital, on Dt.07/12/2012, on Dt. 20/12/2012 when the for the first time claim was made and on Dt.16/08/2012 when the Opposite Parties refused to settle the claim.
And finally the Opposite Party No.2(two) on Dt.16/08/2013 refused to make any such claim amount to the Complainant as such he preferred to file the case in the august Forum along with a number of relevant documents with regard to his insurance policy, about his illness & treatment and claim for an amount of Rs.50,000/-(Rupees fifty thousand)only.
The Forum admitted the case after perusing all the documents, the complaint petition and hearing the advocate for the Complainant and notice along with the complaint petition were served on both Opposite Parties with a direction to file version and any documents if any in their support.
The Opposite Party No. 1(one) and No. 2(two) appeared in the Forum through their Advocates on Dt. 18/03/2014 and subsequently on Dt. 14/06/2014 filed their joint version denying the claim of the Complainant with several grounds. The Opposite Parties have admitted in their version that the Complainant has taken an insurance policy from them but at the same time they claim that it is a contract between both of them wherein he has agreed upon the terms and condition and is bound by that as such should have followed, secondly they have also stated in their version that they would not give any para wise comments on the petition filed by the Complainant, thirdly they have urged that the claim of the complainant is a premature one as he has not yet supplied all the required documents as asked by them, besides that they have claimed to dismiss the petition as it is not maintainable and others.
Since the appearance of the Opposite Parties they took several adjournment at the hearing stage and in continuance of such episode again an adjournment petition was filed on Dt. 16/12/2015.
The Forum was pleased to allow the time petition of the Opposite Parties on Dt. 16/12/2015 for last chance with a condition of payment of Rs.500/-(Rupees five hundred)only as cost to the Complainant but again Dt.11/01/2016 the Opposite Parties neither took any steps nor paid the cost amount as such the Forum was pleased to impose further amount of Rs. 500/-(Rupees five hundred)only as cost but inspite of that the Opposite Parties did neither bother to pay such costs imposed upon them nor attended the Forum as such the Forum was pleased to fix the case to hear on merit from the side of the Complainant with a condition for the Opposite Parties to take part in the hearing by paying the imposed costs on them but to no affect as such the Forum was pleased to fix the case for hearing on merit on Dt. 02/08/2016, but on that day the Opposite Parties had filed their hazira but physically did not attend the Forum even after repeated call whereby the hearing was taken off and heard the case on merit from the side of the Complainant.
Perused the complaint petition filed by the Complainant and the joint version filed on behalf of the Opposite Parties and the documents in volume filed by both the parties and heard the Advocate for the Complainant at length and after scrutinizing all the materials available in the record, we found the following points are the determining points to adjudicate the case properly.
Whether the Complainant was really ill as mentioned in his petition or not.
Secondly whether the Complainant is entitled to the claimed amount of Rs.50,000/-(Rupees fifty thousand) or not.
In this context while adjudicating the case we vividly verified the document filed by both contesting Complainant and Opposite Parties and after hearing the learned Advocate for the Complainant we found that the Complainant is a bonafide consumer having being insured by the Opposite Parties vide his policy No. 005333992 commencing from Dt.18/01/2012 for thirty years which has been admitted by the Opposite Parties, and as per such policy of the Opposite Parties he is being covered for his life and for health care in case of any diseases caused to the complainant during the subsistence of the said policy.
Now while deciding on the question of whether the Complainant was really ill or not, we verified all the detail of the documents filed by him and also the documents filed by the Opposite Party wherein we found that it is clearly evident from the documents of the hospital namely EVISTA CARE CENTRE, Nagpur, the prescription of the doctor and his report and the receipt of the hospital against the payment of the bill amount by the Complainant it is clearly evident that the Complainant was really ill to which the Opposite Parties have also not denied but so far material available in the record they have asked for some more documents as mentioned in their letter to the complainant on date 12/12/2012 wherein also they have acknowledged to have received the material documents filed by the Complainant. And in our view the documents mentioned in the said letter of the Opposite Parties it self besides others is sufficient to prove the case of the Complainant that he was really ill as claimed by him. And accordingly the first point of determination is answered affirmatively.
And so far as the question of the entitlement of the Complainant for an amount Rs.50,000/-(Rupees fifty thousand) only after going through all the relevant documents filed by both the parties we found that really the Complainant has incurred an expenditure of an amount of Rs. 43,477/-(Rupees forty three thousand four hundred seventy seven)only to which the Opposite Parties have also not denied anywhere in their version rather they have only asked the Complainant to submit certain document which has earlier been mentioned and our view is also expressed affirmatively in favour of the Complainant, further more the Opposite Parties have raised a point alleging the Complainant to have violated but in this context our view is that while contacting any party for an insurance policy it is generally seen that the company people pursue the insured person put them in net of word so strongly and convincingly that a lay man can not avoid them and put their consent in their application form without under standing the voluminous and critical texture of the term and conditions of the same and in this particular case also the same thing has happened, moreover in spite of that in our view the Complainant has fulfilled all the criteria of the policy as it is clearly evident from the material filed by him in support of his illness and the treatment he has undergone so no further documents is required to prove case as such his claim for the expenses incurred by him in his treatment all other claim of Rs. 50,000/-(Rupees fifty thousand)only as claimed by him is justified as assured by the Opposite Parties in their said policy, Accordingly ordered.
-: O R D E R :-
Hence the Opposite Parties are liable to pay jointly and severally as such are directed to pay the claim amount of Rs 50,000/-(Rupees fifty thousand)only to the Complainant along with interest @ 9% (nine percent) per annum from the date of filing of the case before this Forum i.e. Dt.03/09/2013 till the date of Order i.e. Dt.21/09/2016 within one months from the date of order and in default in making such payment, they are directed to pay the said amount of Rs. 50,000/-(Rupees fifty thousand)only with interest @ 12%(twelve percent) till the date of actual payment from the date of filing of the case i.e. Dt.03/09/2013.
We pronounced the order to-day the Dt.21/09/2016 in the open Forum and accordingly the case is disposed off.
Typed to my dictation
and corrected by me.
I agree, (Sri Krishna Prasad Mishra)
P r e s i d e n t.
(Sri Pradeep Kumar Dash)
. M e m b e r.
