Date of filing:- 22/03/2023.
Date of Order:-19/02/2024.
DISTRICT CONSUMER DISPUTE REDRESSAL COMMISSION
B A R G A R H (ODISHA).
Consumer Complaint No. 34 of 2023.
Sri Ankit Gupta, son of late Pawan Kumar Gupta, R/o Deepak House, Shakti Nagar, Ward No.11(eleven), Bargarh, Po/Ps/Dist. Bargarh(Odisha), Pin-768028.
..... .... ..... Complainant.
-: V e r s u s :-
Care Health Insurance limited, Unit 604-607, 6th Floor, Tower-C, Unitech Cyber Park, Sector-39, Gurgaon-122001 (Haryana).
..... ..... ..... Opposite Party.
Counsel for the Parties:-
For the Complainant :- Sri Sujit Kumar Dash, Advocate with associates.
For the Opposite Party:- Ex-parte.
-: P R E S E N T :-
Smt. Jigeesha Mishra ..... ..... ..... ..... ..... P r e s i d e n t.
Smt. Anju Agrawal ..... ..... ..... ..... ..... M e m b e r (W).
Dt.19/02/2024. -: J U D G E M E N T:-
Presented by Smt. Anju Agrawal, Member(w):-
1) The case of the Complainant is that the Complainant is earlier a policy holder of Star Health Insurance Co. ltd and under portability changed the policy to the Opposite Party. The Complainant has purchased the one Health Insurance Policy vide Policy No. 31805641 and in the said policy the father and mother along with Complainant were the ensured. The said policy was valid from dt. 26-06-2021 to 25-06-2022. On dt. 10-10-2021, due to some illness the insured No.1(one), the father went for treatment at Saimulti Hospital where due course of his treatment, it was diagnosed that he was suffering from diabetics and some renal(Kidney) issues. Thereafter, the insured No.1(one) was referred to Vikash Hospital and was admitted there from 15-01-2021 to 23-01-2021 for his treatment. That, after treatment the insured was again referred to higher centre to Medicover Hospital, Vizag, where the insured patient was admitted from 24-01-2022 to 11-02-2022. The Complainant for the treatment of insured No.1(one) had spent Rs. 7,80,000/-(Rupees seven lakh eighty thousand)only and as per the policy condition has applied for reimbursement and lodged claim vide claim No.9220 9427. The Complainant has complied all the document to the Opposite Party in time but the Opposite Party dt. 31-05-2022 denied the claim. Being aggrieved by the act of the Opposite Party the Complainant filed the complaint before this Commission praying that the Complainant is entitle to get claim amount of Rs. 7,80,000/-(Rupees seven lakh eighty thousand)only along with Rs.5,00,000/-(Rupees five lakh)only towards compensation for suffering paid and harassment and legal expenses due to deficiency by the Opposite Party.
2) The case of the Opposite Party is that the Opposite Party is that the Opposite Party did not appear before this Commission. Hence Opposite Party is set ex-parte.
3) After perusal of documents as well as oral submission following issues are framed.
Issues
- Whether the Opposite Party is deficient in its service ?
- What relief the Complainant is entitled for ?
Issue No.1(one)
4) After perusal of documents it reveals that the Complainant is having a health insurance policy vide policy No. 31805641 which was valid from 00:00 hrs 26 June 2021 to midnight 25 June 2022 and for the said policy the Complainant has paid Rs.47,414/-(Rupees forty seven thousand four hundred fourteen)only towards premium. In the aforesaid policy the insured were the father and mother of the Complainant. Due to medical reasons the insured No.1(one) father namely Pawan Kumar Gupta was hospitalized at hospital namely for treatment.
The Complainant to substantiate his claim has filed them following documents.
a) Copy of insurance policy.
b) Copy of Care Health Insurance card.
c) Copy of premium acknowledgment.
d) Copy of proposal form “Care Advantage”.
e) Copy of claim denial letter.
For the said treatment, the Complainant had spent Rs. 6,49,080/-(Rupees six lakh forty nine thousand eighty) only and for the reimbursement lodged claim before the Opposite Party vide CL No. 92209427, but the Opposite Party on dt.31-05-2022 vide denial letter denied the claim for the following reasons.
- Deficiency not replied- Hence rejected.
- Deficiency not replied.
The policy commenced from dt.26-06-2021 and the admission of the Complainant/insured was during the validity period and for the said reason, the Complainant is entitled to get the treatments expenses from the Opposite Party but the Opposite Party repudiate its merely by some vague reasons which is not acceptable at all.
When the policy is admitted, claim is admitted, it is the duty of the Opposite Party to settle the claim and the coverage of the said policy is up to 25 lakhs. Hence, denial of claim establishes deficiency in service against the Opposite Party.
5) As per supra discussion, the Complainant is entitled for relief claimed.
Accordingly it is ordered.
O R D E R
6) The Complaint is allowed ex-parte against the Opposite Party. The Opposite Party is directed to pay medical expenses of Rs. 6,49,080/-(Rupees six lakh forty nine thousand eighty) only vide policy No. 31805641 along with Rs. 40,000/-(Rupees forty thousand)only for mental harassment and Rs. 10,000/-(Rupees ten thousand)only towards litigation expenses to the Complainant within one month of this order, failing which the entire order will carry 12% (twelve percent) interest per annum till realization.
7) Accordingly the order is pronounced in the open Commission to-day i.e. Dt.19/02/2024 and the case is allowed against the Opposite Party and disposed off.
Typed to my dictation
and corrected by me.
I agree, ( Smt. Anju Agrawal)
M e m b e r(w).
(Smt. Jigeesha Mishra)
P r e s i d e n t.
