Sri S.K.Sahoo,President.
This petition is filed by the complainant U/s.12 of C.P.Act for the reliefs claimed by him .
2. The case of the complainant is that he is a permanent resident of vill. Jarasingha which comes under the jurisdiction of this Commission . All the opp.parties are having their branch office at Angul and running Life Insurance business through their agent opp.party No.1. Being influenced by the opp.party No.1, the complainant insured himself under their business company Tata AIG G.I.C. The opp.parties received all the required and necessary documents from the complainant such as V.I card, PAN card , photo etc. After proper verification of the same they took the signature of the complaint on their form and papers. The opp.parties received the premium amount from the complainant for Family Floater Plan and issued the policy bearing No. 02357380000 00 . The copy of the policy is Annexsure-1. The opp.parties’ company also issued cash less facility card Medi Prime in favour of the complainant which can be utilised during hospitalization .The ID number of the said card was 00199238432501048 . On 26.11.2017 suddenly the complainant feel pain on his chest and immediately consulted Dr. J.K.Padhee posted at AMRI Hospital (opp.party No.3) . On the advice of the doctor ,the complainant admitted into the hospital on 27.11.2017. He requested for cash less facilities during his treatment and his claim was bearing No. 17112700044 . The opp.parties provided cash less facilities Rs. 1,20,000.00 in favour of the complainant on 30.11.2017 .On receiving the letter relating to cashless facilities from opp.party No.2, the doctor i.e opp.party No.3 started treatment without any objection. Surprisingly on 07.12.2017 when the complainant was about to be discharged from the hospital of opp.party No.3, the opp.party -3 refused to extend the benefit of cashless treatment on the ground that opp.party No.2 has intimated him refusing cashless treatment. Opp.party No.3 demanded an amount of Rs. 1,91,864.00 from the complainant which has been paid by him. After verification of all the documents opp.party No.1 & 2 have wrongly mentioned the age of the complainant in their documents instead of mentioning the correct age. With ulterior motive they have mentioned a false age of the complainant on their documents. The complainant paid the medical dues to opp.party No.3 by obtaining private loan from their relatives. The above conduct of the opp.party No.1 & 2 is deficiency in service, it caused serious mental agony and harassment to the complainant. For the aforesaid reasons the opp.party No.1 & 2 are liable to pay an amount of Rs. 1,00,000.00 towards mental agony harassment, loss, damage caused to the complainant along with other reliefs.
3. Although opp.party No.1 appeared, no show cause was filed.
4. The case of the opp.party No.2 is that the claim of the complainant is not maintainable in the eye of law. The complainant is not a consumer as per Consumer Protection Act. The complainant has availed Family Floater Plan Medi Prime policy for the period 21.10.2017 to 20.10.2018 paying premium of Rs. 10,559.00. The copy of the said policy is Annexure-1. The policy was started from 21.10.2017 and the complainant was admitted to hospital on 27.11.2017 . As per the documents provided to opp.party No.2, symptoms like chest pain started to the complainant 15 days prior to his date of admission . Since 12.11.2017 the complainant sustained pain on his chest. The policy issued in favour of the complainant does not cover the disease which falls within 30 days waiting period which started from the date of policy i.e 21.10.2017 . As the pain felt by the complaint was within the waiting period the claim of the complainant is not a genuine claim. From the medical reports submitted by the complainant it appears that he had under gone ACS treatment on 23.11.2017. On being asked the complainant failed to submit the discharge certificate on 29.11.2017. It further appears from the documents of the complainant that he complaint excessive sweating and pain over his arms for by last seven months prior to his treatment. The complainant didn’t disclose the pre-existence of disease at the time of execution of the policy. On the basis of the cashless facilities policy the complainant was admitted to the hospital of opp.party No.3 on 27.11.2017 and got his treatment. He has spent Rs. 2,31,091.00 for his treatment. The opp.party No.2 denied to extend the benefit of cashless facilities as there is discrepancy in the age of the complainant which was 48 years in the documents of the opp.parties but from the documents of the opp.party No.3 it appears that the complaint is aged about 55 years. The opp.party No.3 on 27.11.2017 sent the pre-authorisation request to opp.party No.2 which was approved by the opp.party No.2 for an amount of Rs. 1,20,000.00 .Even though initially the pre-authorisation request was approved, subsequently it was denied and a letter was issued accordingly to opp.party No.3 due to discrepancy of age of the complainant on the documents. On 07.12.2017 the denied letter was issued to opp.party No.3 by opp.party No.2. The option of reimbursement is open after reconciliation of discrepancies of the age of the complainant. The opp.party No.2 never harassed the complaint and he discharged his service as required by law. There is no deficiency in service on the part of opp.party No.2 . The opp.party No.2 needs no reply to Pra- 1 to 4 of the complaint filed by the complainant.
5. The case of opp.party No.3 is that the case filed by the complainant is not maintainable either in law or in facts. There is no prima-facie case against the opp.party No.3. There is no cause of action against opp.party No.3. No error has been committed by the opp.party No.3 during the treatment of the complainant. The allegations made at Para-1 to 4 and 9 to 15 of the complaint petition are not within the knowledge of the opp.party No.3. On the other hand he admits the contents of Paragraph- 5,6, & 7 of the complaint petition. The opp.party No.3 is a reputed hospital and provided health care service to the general public .The complainant was admitted in the hospital of opp.party No.3 on 27.11.2017 vide patient ID No. AM 40054353 and was under the treatment of Dr. J.K.Padhee . On the request of the complainant he was extended with the facility of cashless, vide Facility Card Medi Prime ID No. 0019238432501046 .The complainant was given treatment by opp.party No.3 only after receipt of valid communication from opp.party No.2 regarding the cashless treatment. On 12.07.2017 the opp.party No.3 received a letter from opp.party No.2 to furnish the treating certificate of the concerned doctor narrating the past history and ailments of the complainant. As the opp.party No.3 received a letter from opp.party No.2 to confirm the age of the complaint with age proof certificate . On the same day opp.party No.3 also received a letter from opp.party No. 2 in which he has denied the cashless facilities. No error has been committed by the opp.party No.3, for which the opp.party No.3 is not liable for any deficiency in service rendered by him.
6. There is no dispute between the parties that the complainant was insured under opp.party No.2 under Family Floater Plan Medi Prime which covered the period from 21.10.2017 to 20.10.2018 . It is also not disputed that the complaint has paid the premium which was received by the opp.party No.2 and cashless treatment facility was extended to the policy holder Akshaya Ku. Sahu and his wife Pramila Sahu . It is also admitted that the complaint was admitted to the hospital of the opp.party No.3 on 27.11.2017 , who treated him after receipt of cashless facilities letter from opp.party No.2. The period of treatment is covered under the policy issued by the opp.party No.2 in favour of the complainant. From the documents issued by the opp.party No. 2 in favour of the complainant it also appears that the reasons of rejection of cashless facilities of the complaint was on the ground of age discrepancy of the patient i.e the complainant. There is no other ground or reasons mentioned in the said letter issued by opp.party No.2 to opp.party No.3 while not extending the cashless benefit to the complainant.
7. During argument the learned counsel for the opp.party No.2 raised several other reasons for not extending the cashless treatment in favour of the complainant . All those reasons raised by the learned counsel for the opp.party No.2 are after thought.
8. It is specific case of the complainant that the opp.parties after receiving all the required and necessary documents from the complainant such as VI Card ,PAN card , photo etc. and after proper verification of those documents, the policy was issued in his favour . At Pra-8 it is also specifically alleged that instead of mentioning the correct age, the opp.party No.2 mentioned a false age with ulterior motive. During argument the learned counsel for opp.party No.2 submitted that on good faith the policy was issued in favour of the complainant without verifying any documents from the complainant. In his written statement opp.party No.2 at Para-8 has stated that there is no need to reply in respect of Para-1 to 4 of the complaint petition. At Para-3 of the complaint petition there is specific allegation against the opp.party No.2 that after proper verification of the documents the policy was issued. The opp.party No.2 in his written statement specifically stated that there is no need to reply the contents of Para-1 to 4 of the complaint. So it is clear from the materials on record that after verification of V.I Card, PAN Card , photo etc and other documents from the complaint the policy was issued. The reliance of the opp.party No.2 on the documents of opp.party No.3 regarding the age of the complainant is of no use. There is no material before this Commission that the complainant has disclosed his age to opp.party No.3 .However in the complaint petition filed before this Commission the complainant mentioned his age as 54 years. From the documents filed by the complainant in this Commission , it appears that the complainant was born on 05.07.1964. If the complainant had intention to give a false age to opp.party No.2 at the time of execution of the policy he could have mentioned his age accordingly in the complaint petition. In the complaint petition the complainant has not suppressed his age before this Commission which is the correct age as per the documents filed by him in this Commission at the time of filing of the case. It appears from the written statement of opp.party No.2 that after verifying the documents the opp.party No.2 has not reflected the actual age of the complainant in the documents prepared by the opp.party No.2 at the time of preparation of the policy. The fault lies with opp.party No.1 & 2 and not with the complainant regarding the discrepancy of the age as alleged by opp.party No.1 & 2. Admittedly the claim of the complainant was rejected only on the ground of age discrepancy on the documents prepared by opp.party No.1 & 2. The actual age of the complainant at the time of filing of the complaint petition was more than 48 years i.e 54 years which he has clearly mentioned in the complaint petition. So as the policy was valid and the reason of rejection of the cashless facilities to the complainant by the opp.party No.1 & 2 is illegal, he is entitled for some reliefs .There is deficiency of service on the part of opp.party No.1 & 2.
9. Hence ordered :-
: O R D E R :
The case be and same is allowed on contest against the opp.party No.1 & 2 The opp.party & 2 are directed to pay an amount of Rs. 1,91,864.00 ( One Lakh Ninety-one Thousand Eight Hundred Sixty-Four) only to the complainant along with interest @9% pa there on from the date of filing of the complaint i.e 02.05.2018 till payment is made. The opp.party & 2 are further directed to pay an amount of Rs. 50,000.00 (Rupees Fifty Thousand) only towards compensation to the complainant for mental agony and harassment. They are further directed to pay an amount of Rs. 15,000.00 (Rupees Fifteen Thousand) only towards litigation cost. All the aforesaid amount should be paid to the complainant within one month of receipt of the order from this Commission, failing which they have to pay interest @ 15% p.a to the complainant till payment is made.
