Orissa

Cuttak

CC/44/2018

Vineet Agrawal - Complainant(s)

Versus

Branch Manager,New India Assurance Co Ltd - Opp.Party(s)

R K Pattanaik & associates

05 May 2022

ORDER

IN THE COURT OF THE DIST. COINSUMER DIUSPUTES REDRESSAL COMMISSION,CUTTACK.

                                                                                C.C.No.44/2018

                                Vineet Agarwal,

S/O:Ratan Kumar Agarwal,

At:Nayasarak,P.O:Chandinichowk,

Dist:Cuttack-753002.                                                                    ... Complainant.

 

                                                Vrs.

1.        Branch Manager,

New India Assurance Company Ltd.,

Cuttack Branch Office,Link Road,

Opp. Arunodaya Market,Cuttack-753012.

 

2.        Heritage Health TPA Pvt. Ltd.,

OCHC Complex,1^st Floor,

Near Ram Mandir,Janapath,

Unit-III,Kharvelanagar,Dist:Khurda,

Bhubaneswar.... Opp. Parties.

 

Present:               Sri Debasish Nayak,President.

                                Sri Sibananda Mohanty,Member.

 

Date of filing:    20.04.2018

Date of Order:  05.05.2022

 

For the complainant:          Mr.R.K.Pattnaik,Adv. & Associates.

For the O.P.No.1:                Mr. A.A.Khan,Adv. & Associates.

For the O.P No.2:                     None.

 

Sri Debasish Nayak,President.

            The case record is put up today for orders

            Case of the complainant as made out from his complaint petition in short is that the complainant had approached the O.Ps for taking health insurance policy and accordingly the agent of the O.P came up to the complainant and explained the features of the policy along with its benefits under the scheme named and styled as “New India Floater Medi Claim Policy”.  The complainant had made the policy with the O.Ps bearing Policy No.55040134152800000044 and the date of commencement was 20.3.16 with its maturity date as 19.3.17.  The said policy covered a sum of Rs.80,000/- with a premium of Rs.42,514/.  During the validity of the said policy, life assured (complainant) suffered abdominal pain and was admitted to Astha Hospital at Dehradun.  The expenses of Rs.16,565/- was made in the hospital of O.P.  Again after some days, the complainant felt pain in the abdomen for which she was hospitalised at Asian Institute of Gastroenterology Pvt. Ltd., Hyderabad where the total expenses was Rs.99,000/-.  After being discharged he made the claim on 18.8.16 but the O.P hesitated to pay the said second claim.  Thereafter, for the third time the complainant was again hospitalised for pain in abdomen at Astha Hospital, Dehradun and had made the third claim also before the O.Ps.  The third time claim to the tune of Rs.16,585/- was paid for the complainant.  Quite surprisingly the second claim was not settled by the O.Ps in spite of several letters written by the complainant in this context to the O.Ps.  Ultimately, the complainant could know that the O.Ps have repudiated his second claim with a plea that it is not payable for which he had to approach this Commission claiming the said amount of Rs.99,000/- along with interest @ 12% till realisation and also a sum of Rs.1,00,000/- for the harassment caused to him together with cost of litigation to the tune of Rs.5000/-.  The complainant has annexed copies of all the relevant documents to support his claim.

2.         On the other hand, O.P No.1 has contested this case and has filed written version wherein he has admitted about the policy executed by the complainant, three claims made by him towards his illness, the first and the third claims of the complainant to have been honoured but according to the O.P No.1 the second claim of the complainant could not be entertained since because the said claim has been repudiated as per the terms of the policy executed in between the complainant and the O.P.  As such, the O.P.No.1 has prayed to dismiss the complaint petition with cost.  To support his stand taken, the O.P No.1 has filed documents also.

            The O.P No.2 has not contested this case and thus been set exparte.

3. Keeping the averments as made out in the complaint petition of the complainant and that in the written version of the O.P No.1, this Commission feels it proper to settle the following issues.

1. Whether the case is maintainable?
2. Whether the claim advanced by the complainant has been repudiated according to law?
3. Whether the complainant is entitled to get the benefits as claimed by him?

Issue No.2:

            For the sake of convenience issue No.2 is taken up first for consideration.  In this context it is noticed that as per the documents and undisputed averments here in this case, the complainant had been hospitalised and was on medical treatment thrice out of which the first and third claims made by the complainant were entertained by the O.P No.1 but as per the O.P No.1, the second claim made by the complainant has been repudiated vide the terms of the policy which the complainant had taken.  To support the plea, the O.P No.1 has filed copy of terms and conditions of policy vide Annexure-B wherein, he has drawn attention towards the point no.4.3.1-16.  According to the O.P No.1 this term as envisaged in the policy excludes the claim made by the complainant for which the claim of the complainant in this score was terminated.

            Now the question is, whether the complainant was disclosed about such terms in the policy when such policy was given effect to.  In this context the burden of proof shifts upon the head of O.P No.1 and it is O.P No.1 who is to prove the plea taken that as per the said term of the policy the claim of the complainant was repudiated.  The said O.P No.1 has neither proved any document nor has elucidated any evidence in order to apprise this Commission that the complainant was well aware and was having knowledge about the term of the policy through which his second claim was not to be entertained.  Thus, in absence of such evidence when the complainant cannot be said to be having knowledge about the said term, this Commission cannot come to a conclusion that repudiation of the policy as per the term which is relied and put forth by the O.P No.1 here in this case was within the knowledge of the complainant.  Accordingly, this Commission cannot come to a conclusion that the second claim of the complainant was repudiated.  Hence this issue is answered in favour of the complainant.

Issue No.1.

            As per the discussions made above, it is noticed that the complainant after entering into the agreement with the O.P by executing the policy and paying the premium which are not disputed; has definitely a cause of action to file this case when his second claim was not honoured. Hence this case is maintainable and this issue is also answered in favour of the complainant.

Issue No.3.

            The complainant is thus entitled for the claims as advanced by him. Hence it is so ordered;

                                                            ORDER

            The case is decreed on contest against O.P No.1 and exparte against O.P No.2.  The O.P No.1 is hereby directed to settle the claim of the complainant to the tune of Rs.99,000/- towards hotel bills within a month hence along with interest @ 12% per annum till the settlement is made finally.  The O.P No.1 is further directed to pay a sum of Rs.60,000/- to the complainant towards mental agony and harassment caused to him by O.P No.1 together with litigation cost of Rs.5000/- to be paid by O.P No.1 to the complainant.  This order is to be carried out within a month hence.

Order pronounced in the open court on the 5^th day of May,2022 under the seal and signature of this Commission.

 

                                                                                                                             Sri Debasish Nayak

                                                                                                                                        President

 

                                                                                                                       

                                                                                                                            

                                                                                                                         Sri Sibananda Mohanty

                                                                                                                            Member.