Orissa

Cuttak

CC/115/2023

Manas Ranjan Ojha - Complainant(s)

Versus

Care Health Insurance Co Ltd - Opp.Party(s)

23 Jul 2024

ORDER

IN THE COURT OF THE DIST. CONSUMER DISPUTES REDRESSAL COMMISSION,CUTTACK.

C.C.No.115/2023

Manas Ranjan Ojha,

S/o: Bata Krushna Ojha,

At:Mirkamal Patna,P.O/P.S:Mangalabag,

                  Town/Dist:Cuttack                                              ...Complainant

 

          Vrs.

 

1.         Manager Legal,

M/s. Care Health Insurance Co. Ltd.,

                 Unit-604,607,6th Floor,Tower-C,

Unitech Cyber Park Sector-39,

               Gurgan-122001,Stte-Haryana.

 

2.       Branch Manager,

M/s. Care Health Insurance Co. Ltd.,

Plot No.4/1478,Khatian No.487/139,

               Bagbarundaban,Dist:Balasore,

Pin-756001.

 

3.       Manager,Head Office,

M/s. Care Health Insurance Co. Ltd.,

            5^th floor,19 Chawla House Nehru Place,

       NewDelhi-110019.                                                      ...Opp.Parties

 

Present:         Sri Debasish Nayak,President.

                      Sri Sibananda Mohanty,Member.

 

Date of filing:    17.04.2023

Date of Order:  23.07.2024

 

For the complainant:            Mr. G.C.Behera,Adv. & Associates.

For the O.Ps               :            Mr. A.A.Khan,Adv. & Associates.

 

Sri Debasish Nayak,President.

Case of the complainant as made out from the complaint petition bereft unnecessary details in short is that he had obtained a Health Care policy from the O.Ps for himself, his wife and his son  vide policy number 61514152 where the assured value was of Rs.5,00,000/-.  On 6.2.2023, the complainant had fallen from stair case and thereby had sustained pain at his backside spine.  He was admitted to AMRI Hospital on 8.2.2023 and was under the treatment of Dr. Amit Jaiswal there.  The complainant had raised his claim before the O.Ps intending for cashless treatment and had provided to them all the necessary documents in order to process his claim but the claim of the complainant was repudiated by the O.Ps as they had opined that the case of the complainant is a case of Arthritis which is not covered under the policy as obtained by the complainant.  It is for the said reason; the complainant has come up with his case before this Commission seeking a sum of Rs.10,00,000/- from them towards compensation alongwith cost of his litigation as well as interest thereon and has also alternatively prayed for any other order as deemed fit and proper.

          Together with his complaint petition, the complainant has filed copies of several documents in order to prove his case.

2.       The O.Ps have contested this case and have filed their joint written version.  According to their written version, the case of the complainant is not maintainable which is liable to be dismissed.  According to them, the insurance policy is a contract of outmost good faith wherein the assured is to disclose about his previous ailments without suppressing those and if in case of any pre-existing disease which is not disclosed rather suppressed, the same will render the agreement/policy to be void.  It is further pleaded by the O.Ps in their written version that the case of the complainant is bad for non-joinder of necessary parties.  They have relied upon catena of decisions which are as follows: -

In the case of Expert Credit Guarantee Corp of India Ltd. Vs. M/s.Garg Sons International the Hon’ble Supreme Court of India was of the view that “The insured cannot claim anything more than what is covered by the insurance policy. ‘….. the terms of contract have to be construed strictly, without altering the nature of the contract as the same may affect the interests of the parties adversely.”

In the case of Bajaj Allianz General Insurance Co. Ltd. Vs. Rameshbhai Shivabhai Patel & Ors (Appeal no.628/2014), the Hon’ble State Commission of Gujarat overturned the District Forum, Vadodara’s order and has held that the treatment for spinal cord is only covered after 4 years of policy inception.

In the recent case of SGS India Vs. Dolphin International Ltd. LL 2021 SC 544 the Hon’ble Supreme Court was of the view that “The onus of proof of deficiency in service is on the complainant in the complaints under the Consumer Protection At,1986.  It is the complainant who had approached the Commission, therefore, without any proof of deficiency, the opposite party cannot be held responsible for deficiency in service.”

In this regard, the bench referred to the decision in the case of Ravneet Singh Bagga Vs. LKM Royal Dutch Airlines (2000)1 SCC 66 in which it was observed thus: “The deficiency in service cannot be alleged without attributing fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance which is required to be performed by a person in pursuance of a contract or otherwise in relation to any service.  The burden of proving the deficiency in service is upon the person who alleges it.”

The court also noted that in the case of Indigo Airlines V. Kalpana Rani Debbarma (2020) 9 SCC 424, it was held the initial onus to substantiate the factum of deficiency in service committed by the opposite party was primarily on the complaint”.

In a recent judgment in the case of City Union Bank Vs. R. Chandramohan (Civil Appeal No.7289 of 2009) pronounced by Hon’ble Supreme Court of India vide order dated 27.3.2023 held that “the “deficiency in service”, as well settled, has to be distinguished from the criminal acts or tortious acts.  There could not be any presumption with regard to the wilful fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance in service, as contemplated in /section 2(1)(g) of the Act.

Thus, in total, it is the contention of the O.Ps to dismiss the complaint petition with heavy cost.

          Together with their written version, the O.Ps have  annexed copies of several documents in order to support their stand.

          The O.Ps have also filed their evidence affidavit through one Sahil Chauhan working as Manager(Legal) in their company but the contents of the said evidence affidavit of said Sahil Chauhan when perused, it appears to be a reiteration of the contents as made in the written version of O.Ps.

3.       Keeping in mind the averments as made in the complaint petition and the contents of the written version of the O.Ps, this Commission thinks it proper to settle the following issues in order to arrive at a definite conclusion here in this case.

i.          Whether the case of the complainant is maintainable?

ii.         Whether there was any deficiency in service on the part of the O.Ps and if they have practised any unfair trade ?

iii.        Whether the complainant is entitled to the reliefs as claimed by him?

Issue no.II.

Out of the three issues, issue no. ii being the pertinent issue is taken up first for consideration here in this case.

After perusing the complaint petition, written version, written notes of submission as filed from both sides, evidence affidavit filed by the O.Ps  as well as the copies of documents available in the case record, it is noticed that admittedly, the complainant Manas Ranjan Ojha had obtained a Health Insurance policy for himself, his wife Banita Maharana and daughter Sai Smruti Ojha wherein the sum assured was of Rs.5,00,000/-.  It is not in dispute that the complainant Manas Ranjan Ojha had fallen down from his stair case on 6.2.2023 and was admitted to AMRI Hospital on 8.2.2023.  Admittedly, he had put-forth his health insurance claim but it was repudiated by the O.Ps on the ground that his case was that of “Arthritis” which is not covered under the policy plan as availed by the complainant.  In this context while perusing the letter of repudiation (denial letter) of the O.Ps whose copy has been annexed by the O.Ps alongwith their written version in this case, vide Annexure-C, it is noticed that they have urged therein about “30 day waiting period”.  While probing further into the terms and conditions of the policy copy as provided by the O.Ps here in this case, it is noticed that as per Clause-4, exclusions vide clause-4.1(i)(a) “expenses related to the treatment of any illness within 30 days from the first policy commencement date shall be excluded except claims arising due to an accident, provided the same are covered”.  As it appears here in this case, the insurance policy as availed by the complainant was effective from 31.1.2023 till 30.1.2024 midnight.  The complainant had fallen from his stair case on 6.2.2023.  Thus according to the O.Ps,  30 days exclusion period is applicable here  but they have not disputed about the complainant falling down from his stair case which undoubtedly is an accident.  There is mention about the accident if to have been covered in order to avail the benefits of the policy but the O.Ps have not apprised this Commission that if spinal pain is not covered, which had occurred due to falling down from the stair case.  As per their written version, the case of the complainant was a case of Arthritis which was not covered under the policy.  It is not understood as to where from the O.Ps could conclude that the case of the complainant was a case of Arthritis.  It is because, nowhere the treating doctor of AMRI hospital, Dr. Jaiswal had mentioned that the complainant was suffering from any Arthritis problem. Thus, the repudiation as made here in this case thereby denying the benefits of the health insurance policy to the policy-holder/complainant appears to be a deficiency in service on the part of the O.Ps no.1 & 2 which also indicates that they have practiced unfair trade by denying the genuine claim of the complainant.  Accordingly, this pertinent issue goes in favour of the complainant.

Issues no.i & iii.

From the discussions as made above, the case of the complainant is maintainable and he is entitled to the reliefs as claimed by him from the O.Ps.  Hence it is so ordered;

 

 

ORDER

The case is decreed on contest against the O.Ps who are found to be jointly and severally liable here in this case.   The O.Ps are thus directed to pay the complainant towards compensation for his mental agony and harassment as well as litigation expenses a sum of Rs.4,00,000/- towards his insurance claim alongwith interest thereon @ 12% per annum from the date of his claim till the amount is quantified.  This order is to be carried out within a period of 30 days from the date of receipt of copy of this order.

Order pronounced in the open court on this the 23^rd day of July,2024 under the seal and signature of this Commission.         

 

                                                                                      

                                                                                      Sri Debasish Nayak

                                                                                              President

 

 

                                                                                          Sri Sibananda Mohanty

                                                                                                      Member