Orissa

Jajapur

CC/86/2015

Smt.Suprava Kumari Routray. - Complainant(s)

Versus

Branch Manager National Insurance Co.Ltd - Opp.Party(s)

P.K .Das Pattnaik

21 Mar 2018

ORDER

   IN THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, JAJPUR.

                                                        Present:      1.Shri Jiban ballav Das , President

                                                                            2.Sri Pitabas Mohanty, Member,

                                                                            3.Miss Smita Ray, Lady Member.                      

                                              Dated the 21^ST  day of March ,2018.

                                                 C.C.Case No.86 of 2015

1.Smt. Suprava kumara Routray ,  W/O Dr.Hemanta Kishore Sahoo

2.Dr. Hemanta Kishore Sahoo, S/O Late Lambodar Sahoo

Both are Resident of at Health shade ,Mohatma Gandhi Marg

P.O/P.S/ Jajpur Road, Dist. Jajpur . 

                                                                                                                           …....Complainant .                                                                 .

                   (Versus)

1.Branch Manager, National Insurance Co.Ltd, At.Jaganathpur,

P.O/P.S/Keonjhar

2.Sr. Divisional Manager, National Insurance Co.Ltd, division-1,Cantanment Road,

Cuttack.

3.Regional Manager,National Insurance Co.Ltd, At.Iddco Tower 6^th floor,BBSR

4.Medi Asst. India T.P.A.Pvt.Ltd, 53-a Rati Ahammed,Kidnai Road opposite

Hotel Gulsan near Rippow Street,Kolkata.

5.Genins India T.P.A Ltd, 402, Janapath Tower ,4^th floor,Ashok Nagar ,BBSR.

6.Branch Manager, National Insurance Co.Ltd, Jajpur Road branch ,At/P.O. Jajpur Road

Dist,Jajpur.

                                                                                                                          ……………..Opp.Parties.      

For the Complainant:                                  Sri P.K. Daspattnaik ,Advocate.

For the Opp.Parties : No.2.                          Sri K.C.Kar,Advocate .

For the Opp.Parties No. 1,3,5 and 6            None        

                                                                                                Date of order:  21. 03.2018.

MISS  SMITA  RAY  , LADY  MEMBER  .

Deficiency in medi- claim  insurance is the grievance of the petitioner .

            The facts as per complaint petion as stated   by  the petitioner are that she being the  sr.citizen  has obtained a mediclaim policy jointly with  her husband  from o.p. no.1 in  her own name  as well as in their joint names ,   in the name and style of sr.citizen mediclaim  policy prior to obtaining  the mediclam policy,  the O.P  Insurance company made detail health check of the petitioner by a  medi-claim practitioner .  During the continuance of  the policy in the year 2011 all on a sudden the petioner no. -1 fell ill  for loss of memory due to cerebral,  infraction and was required to consult with the  specialities   hospital for  further course of treatment . By way of an immediate concern through   letter dt. 09.07.12  and 15.09.12 the matter has been informed to the O.P.no.-1 insurance company .Thereafter  on  24.12.12 all the papers containing details of treatment medical bill and pathological  test  report have been forwarded to the  O.P . Insurance company for early settlement  of the claim .  After  receipt of such information  ,   the O.P.no. 1 did not  turned up .  Thereafter during the course of treatment the husband of the petitioner many times wrote letter to the O.P.no.1  but it was not responded by the Insurance company . However on 21.10.13 the petioner-1   herself after her partial  recovery of the said deceases   wrote a letter to the O.P.no.1  for early settlement of her claim . During the continuation of her  own treatment ,  the petitioner has spent Rs. 88,343/-  from 25. 06.12 to till 12. 02.14 but due to latches of O.P.no.1 she could  not  able to get any amount from the insurance company . However in the year of  2013 ,  as per advice of O.P.NO.1 again the claim of the petitioner was resent to O.p.NO.4 who is the authorized   agent of the op. 1 to look after the mediclaim  policy affairs . That in the mean time the treatment of the petitioner was going on,  again from  12.12.14 for which  the petitioner-2  again submitted the reimbursement claim  to the O.P.no.1 along with other documents  and bills,  vouchers for settlement  of her expenditure incurred for the year 2013-14  . After   receipts  of all documents,  the  O.P.no.4   on 05.03.14  wrote a letter to  the husband of the petitioner i.e petitioner-2  that on scrutinizing the claim ,  it is found that the said claim does not fall under the policy and the category under which the said policy has been issued . Further the O.P.no..4  is not service provider of DPA  . it is alleged by the petitioner  that though  the policy condition  clearly allowed the cost of the hospitalization medicine  bill  and also allow the domiciliary   treatment ,  but now the O.P.no. 1 with an alterior motive with the assistance  and in collusion  with  O.P.no. 4 has not  decided  the genuine claim of the petitioner . It  is restated here that under policy no.163006148/11/8500000947  dt.10. 01. 12 while the TPA genins  India Ltd. Treatment  started on   dt.26.06.11  continuing 1^st claim  was submitted to N.I. Co Ltd   for Rs.61,680/-  on 23.12.12     and there was no response  from N.I. Co. Ltd  and  Geninis India ltd  .  However  claim for policy No.163006148  /12/85 00001238 dt.10.01.13 was during  on the TPA   Asst. T.P.A India Ltd  the 2^nd  claim submitted on 12.2.14 .           

2. No response of  O.P no. 1 and 2 as well as  from medi Asst. TPA  .By changing TPA  by  the insurance claim and not protecting the interest of insurers rather protecting the insurance company or  TPA same is  made out  with a malafide  intention and to harass the insurer . The petitioner to pay the the premium to the insurance company  not to  the TPAS  , so it is the sole  and prima facie duty    of Insurance company to  settle  the claim  of  the petitioner. The correspondnece made by the  Insurance company   TPA  is so cunning  that  the Insurance Company  and TPAS  are hand in glove  to harass   the insurer .That the petitioners are old  and more than 76   years  old . In the said state  of affairs she is not in a condition to run from  pillar to post  for settlement of her genuine claim. Accordingly the petioner knocked to door of this  fora with the prayer to direct the O.Ps.      to pay the entire claim amount with penal interest as  claimed   by the petitioner  under the terms  and conditions  of the medi claim  policy  . Besides this  the petitioner may be  awarded compensation amount for Rs.50,000/-  for  her physical and mental suffering .

            There are  6 nos of O.Ps of the dispute  though notice to  the present  O.Ps was duly served   except O.P.no. 4 and  the  notice   was returned against O.P.no.4 .  There are several oppertunity  was given by this Fora  to  the petitioner for taking step regarding service of the notice against O.P.no. 4 but petitioner did  not turn  up .

            After perusal of the record except O.P.no.2,  other O.Ps have not choose to contest the dispute  though  several opportunity was  given by this fora for appearance and filing written version  by the concerned O.Ps  .Hence the O.P.no. 1,3,5 and 6 have been set exparte vide order  dt.8./2/17 . The O.P.no.2 appeared through their learned  advocate and  subsequently filed the written version   taking the  following stands .

1. The complaint petition as laid down is neither maintainable in facts nor in law and the same is liable to be dismissed with cost.
2. The facts contains on the complaint petition of the petitioner are not admitted by this O.P no.2  as all are far from the truth and the same has deliberately  made with an avoid oblique motive of prejudicing this Forum.

3.The claim does not fall under the police and the category  under which the said policy  has been issued .

4. This O.P is not liable to settle  the claim as per the provision of law.

5.The claim of the petitioner has no  merit  and  is liable to be dismissed.

            On the date of hearing we heard the argument from the side of the petitioner.

Perused the pleadings and documents available on record.

1. It is to be decided whether the petitioner is  a consumer ?

2. Whether the pettiioner is entitled  further relief sought for and whether the O.Ps are  liable to settle the claim nor the petitioner .

1. It is undisputed facts that the petitioner availed such mediclaim policy from O.P no.1 and 2 (Insurance company)

2. During subsistence of policy the petitioner no.1 fell ill  due to  loss of memory  for  cerebral ,infraction and was  required to consult  super speciality  hospital for her further course of treatment and by way of an immediate concerned on letter dt. 09.07.12  and 15.09.12   , the matter has informed to the o.p (insurance company) Thereafter the petitioner lodged claim and produced all documents and expenditure voucher before the O.ps insurance company for reimbursement of their expenses during course of treatment in the hospital .

3. when the claim was not settled  the petitioner approached through various reminders and personal approach and  as per the instruction of the Insurance company   the claim of the petitioner was re-sent   to O.P.no. 4 who is the authorized agent of  Insurance company to look after the mediclaim  policy affairs of  Insurance  company .

5. On the other hand the O.P.no.1 ,3,5 ,6 neither appeared nor to choose to contest the dispute by  filing any objection  or written version , though the notice of present dispute is duly served upon them .  Hence we are unanimously to accept the statement of the petitioner made in the complaint petition  as unconroverted as per observation of Hon,ble  S.C Orissa reported in 2003-vol-96-p-15   C.D. case no.37/02   wherein in it held that  :

“ in absence of written version  by the O.P  this commission is bound to accept the uncontroverted statement made  in the complaint  petition   and 2013(1)  CPR-506 , wherein it is held that:

            “In case of written version  not filed after several opportunity  it has no defence on merit”.

            Thereafter we verified   the written version from and observed there is no  pleading /contention from the side of O.P.no.2 regarding merit of dispute but  simple  deniel of   the complaint  filed from the side of the petitioner . Accordingly we are inclined to hold  that the blame shall be placed at the door of the O.Ps.  As such to meet the ends of justice we allow the dispute  treating the petitioner statement of the complaint petition as uncontroverted .

Hence this order :-

            The dispute is allowed against the O.Ps  -1 and 2 . The O.P.no.1 and 2 are  directed to settle the  claim of the petitioner within one month after receipt of  this order, failing which the claim amount  will carry 9 %  interest from the date of filing of the present disputer till its realization . The petitioner can recover the same by   initiating  the  proceeding as per sec .25  and 27 of C.P  Act.1986.

                        This order is pronounced in the open Forum on this the 21st day of March,2018 under my hand and seal of the Forum.