Date of filing:- 01/07/2015.

Date of Order:-13/04/2018.

DISTRICT CONSUMER DISPUTE REDRESSAL FORUM (COURT)

B A R G A R H.

Consumer Complaint No. 41 of 2015.

Sri Akash Kumar Agrawal, S/o Ramniwas Agrawal, R/o. Bargarh, Shakti Nagar, W.No.11(eleven), Bargarh Po/Ps/Tahasil/Dist. Bargarh                                                                                                                                                                      ..... ..... ..... Complainant.

-:V e r s u s:-

1. Branch Manager, the Oriental Insurance Company Ltd., Bargarh Brach, N.H.6(six), Ambika Cmplex, Bargarh.

2. Managing Director of Oriental Insurance Company Ltd., Oriental House, P.B. No.7037, A-25-27, Asaf Ali Road, New Delhi-110002.

3. Managing Director of M/s Heritage Health Service Pvt. Ltd., Nicco House, 5^th Floor 2 Hare Street, Kolkata-700001.

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

Counsel for the Parties:-

For the Complainant :- Sri B.Behera, Advocate with other Advocates.

For the Opposite Party No.1(one)

and Opposite Party No.2(two) :- Sri P.Mahapatra, Advocate with other Advocates.

For the Opposite Party No.3(three):- Ex-parte.

-: P R E S E N T :-

Sri Krishna Prasad Mishra ..... ..... ..... ..... ..... P r e s i d e n t.

Ajanta Subhadarsinee ..... ..... ..... ..... ..... M e m b e r (W).

Dt.13/04/2018. -: J U D G E M E N T:-

Presented by Sri Krishna Prasad Mishra, President:-

Brief facts of the case ;-

Having being persuaded by the Provision U/s 12 of the Consumer Protection Act 1986 the Complainant has preferred to file the case pertaining to the deficiencies of service on the part of the Opposite Parties on the following ground.

The Complainant being persuaded by the policy of the Opposite Parties company purchased one Med claim Policy to safe guard his health and the health of his family Members namely Happy Family Floater Policy bearing No-34560/48/2014/234 by paying the due amount of premium.

During the subsistence of the said policy period the father of the Complainant while traveling suddenly felt severe chest pain and was treated at the Narayan Institute of Cardiac Sciences at Bangalore which cost an amount of Rs. 30,646/-(Rupees thirty thousand six hundred forty six) only, And after his recovery the Complainant placed his claim for the same amount before the Opposite Parties, but his case is that instead of paying the claim amount deferred with some or other pretext and finally repudiated the same on Dt.04.10.2013 on some baseless ground even if his several reminder to the different authorities which caused him a great mental agony & physical harassment for which the cause of action arose in filing the case. And to substantiate his case has relied upon some following documents claiming an amount of Rs.50,000/-(Rupees fifty thousand)only besides the insured amount and for litigation cost amounting to Rs.10,000/-(Rupees ten thousand)only.

1. Policy Bond bearing No-345601/148/2013/81.

2. Personal Copy of Notice issued by Akash Kumar Agrawal in favor of Branch Manager, Oriental Insurance Company Ltd.

3. Postal receipt.

4. Postal A.D. signed by the Branch Manager, Oriental Insurance Company Ltd.

5. Claim form along with Expenditure Schedule sent to Oriental Insurance Company by Akash Kumar Agrawal.

6. Letter Dt.04.10.2013 issued by the Oriental Insurance Company in favor of Akash Kumar Agrawal.

7. Documents showing the treatment of Ramniwas Agrawal at Narayan cardiac sciences.

Having gone through the Complaint, it’s supporting documents and on hearing his counsel the case seemed to be a genuine one as such admitted and notice was served on the Opposite Parties and in response the Opposite Party No.1(one) & No.2(two) appeared before the Forum but the Opposite Party No.3(three) did not appear even the service of summon was sufficiently served upon him as such was set Ex-parte.

Though the Opposite Party No.1(one) & No.2(two) appeared Dt.06.08.2015 but after a long lapse of time filed their version on Dt.09.08.2016 repudiating to the claim of the Complainant on the ground stated therein as mentioned in their version, it has been contended in their version that the Complaint is not maintainable in view of the agreed terms & condition envisaged therein at the time of commencement of the policy, in it’s version it has put much emphasis on the Clause 4.1 that pre-existing ailments whether declared or undeclared would be taken into consideration while the case of settlement of the claim if any would arise for each and every member of the family in the instant policy, further it has also contended that as per the policy in question being serviced through the TPA/Opposite Party No.3(three) as per their clause 5.14 (a ) and if the same found admissible within the terms & condition of the policy, payment of such claim shall be made through TPA/Opposite Party No.3(three).

In furtherance to their case the Opposite Parties, to justify their repudiation to the claim of the Complainant have contended that on the claim of the Complainant before the treatment for cashless treatment when he was admitted in the Hospital, the TPA/Opposite Party No.3(three) denied to sanction the cashless authorization with a reason as per his finding from the materials produced before him that the deceased is a pre-existing one. So also denied to the indemnification of the expenses made by the Complainant after the treatment and production of the documents to that effect before him with the same plea with a letter addressing to the Complainant to have given him an opportunity to clarify his case within two weeks and as he failed, the former repudiation stands further final repudiation. And to justify their such stand to have shown more reason in addition to the averments made earlier in their version and to substantiate their case the Opposite Parties have relied upon the following documents.

1. True Copy of the Insurance Policy with terms and condition. (twenty one sheets).

2. Xerox Copy of letter of Opposite Party to the Complainant. (one sheet).

3. Xerox Copy of letter of Branch Manager of Opposite Party to regional office with copy of letter of Complainant. (two sheets).

4. Xerox copies of letter of Heritage Health TPA Pvt Ltd. with entire claim file including medical papers submitted by Complainant for the claim.

    

Delving deep in to the matter after examining the complaint his documents and the version of the Opposite Party No.1(one) & No.2(two) and their supporting documents. We feel necessary to adjudicate the case basing on the following points.

1. Whether there is deficiencies of service towards the claim of the Complainant and have caused unfair trade practice on the part of the Opposite Parties.

2. Whether the Complainant is entitled to the claim amount.

While adjudicating the point as to whether there is any deficiencies in rendering due service to the Complainant and there has been commitment of unfair trade practice on the part of the Opposite Parties. It came to our notice first that the Advocate for the Opposite Party No.1(one) appeared before the Forum on Dt.06/08.20125 but has filed the version for him alone on Dt.09.08.2016 after taking several adjournments on the ground stated therein where from it can be safely deduced the negative attitude of the Opposite Parties further he has obtained the No objection of the Opposite Party No.2(two) to the version of the Opposite Party No.1(one) after a long interval, in addition to that the Opposite Party No.3(three) has not even appeared before the Forum consequently has been set ex-parte, who has got a vital role in raising the cause of action.

Further to our observation it has been admitted by the Opposite Parties with regard to the commencement of the policy in question and also the treatment undergone by the father of the Complainant but the sole points of the repudiation of the claim of the Complainant rest on the report of the Opposite Party No.3(three), on the basis of report of whom the claim has been repudiated, here it is pertinent to mention that, though it has been clearly written in the policy terms and condition that any claim which arises in the instant case would be dealt with by the Opposite Parties No.3(three), the TPA/Opposite Party No.3(three), and accordingly the matter of claim has been referred to him on his report the said claim of the Complainant has been repudiated, But for such action of the Opposite Party No.3(three), the sole Managing Director who is supposed to be the sole administrator of the Company has not taken any steps to ensure his appearance before the Forum which creates a clouds of doubt in the mind of the Complainant and the Forum too, the evidence or reply of whom to the case of the Complainant is highly required and in such circumstances his report has got no meaning as per law in our view too. But on the contrary on perusal of the materials placed by the Complainant it seems to be genuine one in the case of his intentional absence and by not filing any version from his end before the Forum.

Furthermore the documents wherein the terms and condition envisaged about the policy is so voluminous that it is not possible on the part of a lay man like the Complainant to be thorough about the same and more over even if the pre-admission of hyper tension by the Complainant in the case of his father, the victim of the case has declared in the form relied on by the opposite parties where from they claim that the claimed incident of chest pain is an outcome of the same is not tenable as the sole cause of the same because it cannot be opined by a lay man like the Opposite Party No.3(three) without having any medical back ground siting in his office chamber, on the basis of which any decision can be taken accordingly in furtherance to the above mentioned attitude of the Opposite Parties mentioned in the last paragraphs, hence in view of the aforesaid circumstances our consensus view is expressed against the Opposite Parties.

Secondly with regard the points whether the Complainant is entitled to the claim as sought for by him, in this context since we have already discussed the case in details in our foregoing paragraphs and have answered in favor of the Complainant, coupled with the failure of the Opposite Parties to proof their case against the case of the Complainant. Now we don’t have any second thought but to answer in affirmative to the case of the Complainant so also with his claim, for which all the Opposite Parties are jointly and severally liable hence our order follows.

-: O R D E R :-

Hence the Opposite Parties are Jointly and severally directed to pay to the Complainant an amount of Rs.30,646/-(Rupees thirty thousand six hundred forty six)only with an interest @ 9%(nine percent) per annum from the date of filing of the case till the date of this order and an amount of Rs.3,000/-(Rupees three thousand)only as compensation for his mental agony and cost of litigation within thirty days of receipt of the order, in default of which the total amount will carry an interest @ 12%(twelve percent) per annum till the actual date of realization of the total amount.

Accordingly the order is pronounced in the open Forum to-day i.e on Dt.13/04/2018, in the result the complaint is allowed against the Opposite Parties, and the case is disposed off .

Typed to my dictation

and corrected by me.

 (Sri Krishna Prasad Mishra)

            P r e s i d e n t                                I agree

                                                   (Ajanta Subhadarsinee)

                                                        M e m b e r (w)