DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KANDHAMAL, PHULBANI
C.C.NO.23 OF 2018
Sri. Ranjan Kumar Sahu
S/O: Sri Judhister Sahu
AT-Masterpada, Totasahi
PO/PS- Phulbani town, Dist- Kandhamal. ……………………….. Complainant.
Versus.
1. Chief Manager,
L.I.C Phulbani
Dist.- Kandhamal
2. Senior Divisional Manager
Divisional Health Unit
L.I.C, Division Office
AT/PO- Berhampur, DIST_ Ganjam …………………………….. OPP. Parties.
Present: Sri Purna Chandra Mishra - President.
Sri Sudhakar Senapothi - Member.
For the Complainant: Manoj Kumar Sahoo & Others
For O.P.1& 2 - B. K. Mohanty
Date of Argument: 20.06.2022
Date of Order: 30-06-2022
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JUDGEMENT
Mr. Sudhakar Senapothi. Member
The complainant Mr. Ranjan Kumar Sahu has filed this case U/S 12 of the C.P Act 1986 alleging deficiency of service on the part of the OPs for non-payment of his insurance claim in spite of repeated approaches and praying therein for a direction to the OPs to pay a sum of Rs.1,00000/- along with 10% excess from the insured amount with interest @12% from the date of claims i.e.06.05.2017,ICU and bed charges of Rs.61,000/-, compensation of Rs.30,000/- for mental agony and Rs.5000/- towards cost of litigation.
- Brief fact leading to the case is that the petitioner has availed one health insurance policy bearing No.573433568 with annual premium of Rs.5612/- starting from 14.02.2013 in which the sum assured was Rs.1,00000/-. During the force of the policy the petitioner met with an accident in his bathroom on 10.10.2016 where he sustained head inquiry and was treated at OM Suvam, Hospital from 12.10.2018 to 27.10.2016 and during this period, he incurred an expenditure of Rs.76,292/-. In spite of the treatment as there was further complicacy he went to Seven Hills Care Pvt. Vizag in the state of Andhra Pradesh and was admitted on 29.10.2016 and discharged on 13.11.2016 where he incurred expenditure to the tune of Rs.6,28,747/-. After recovery from illness, he intimated the fact to the OPs and submitted the claim form on 06.05.2017 for reimbursement of the amount spending for his treatment. After receipt of the claim form, the OPs instructed to the complainant to submit the indoor case papers, discharge certificate and the final bills relating to the treatment. Even though all the documents required by the OPs were submitted by the complainant, no steps were taken to release the claim which was never done and finally the claim was repudiated on 31.03.2018 for non-production of required papers. It is believed that as per the policy condition, the complainant is entitled to Rs, 2000/- per day for his treatment in ICU and Rs, 1000/- for bed per day. He was in ICU for 22 days and in bed for 26 days, similarly as per the policy, if the insured never claimed the insured is entitled to get 10% excess on the insured amount every year till the claim and the OPs intentionally in order to devoid the complainant of such benefit, they are continuously issuing letters and asking the complainant to furnish the papers. As the OPs deliberately and willfully repudiated the claim, he has filed this case before this Commission for the reliefs as prayed for in the complaint petition.
- After receipt of notice, the OPs appeared through their advocates and filed written statement. In their written statement, the OPs admitted the fact that the complainant had taken the health insurance policy in question wherein there was
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provision for initial hospital benefit of Rs.1000/- for each insured member of the policy and there is no provision for sum assured of Rs.1, 00000/-, The OPs stated that they came to know regarding the ill health caused due to accident inside the bathroom and his treatment in Om Suvam Hospital at Ranihat, Cuttack from 12.10.2016 to 27.10.2016 on 06.05.2017. The complaint had submitted the claim application for Rs.76, 292/- on 06.05.2017, but had not submitted the required papers regarding his treatment along with his application. He submitted his second claim application on 14.08.2017 for his further treatment from 29.10.2016 to 13.11.2016 for Rs. 6, 28,747/-. He filed the first application on 06.05.2017 and must have submitted the second application on the same day as his treatment was over on 13.11.2016. The petitioner has not submitted the details regarding the treatment for which he was directed to submit his papers. He was repeatedly requested by the Insurance Company to submit the paper on 20.06.2017, 27.06.2017, 04.09.2017. The OPs repeatedly requested him to submit the documents in support of his treatment along with discharge certificate and final bills but he failed to submit the paper for processing the claim. As the documents were not received, the claim was rejected on 30.03.2018 for non-submission of required documents. Since the OPs are no way deficient in rendering service, they pray for dismissal of the complaint petition with cost.
- The petitioner in support of his case has filed the status report of the insurance policy no.573433568 dtd.27.07.2018, copy of the reminder issued by LIC Health Insurance Division Office, Berhampur dtd. 04.10.2017 to the complainant, copy of the cash bill issued by Seven Hills,dtd.13.11.2016, copy of the bills of Om Suvam Hospital, copy of the repudiation letter of the insurance company dtd.31.03.2018. Copy of the treatment details of Om Suvam Hospital and Seven Hills Health Care Pvt. and the preliminary treatment prescription of Govt. hospital, Phulbani. On the other hand,the petitioner has filed his evidence in shape of affidavit.
On the other hand, the OPs have filed the copy of the policy bond, copy of the petition by the complainant Ranjan Kumar Sahu on dtd.14.08.2017, copy of the letter dtd.04.09.2017 addressed to the complainant by the OPs, copy of the letter of LIC addressed to the complainant on dtd.04.10.2017, copy of the repudiation letter dtd.31.03.2018 in support of their case. The OPs have not filed any oral evidence in support of their case.
- The only point for adjudication is whether the petitioner has provided all the relevant documents to the OPs for processing of his claim or not? It is seen from the documents on record that the complainant has filed copies of all the relevant documents before this Commission which have been specified in the written statement of the OPs such as, indoor treatment case papers, discharge certificate,
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final bills relating to the treatment along with the detail narration of incidence, HOW, WHEN and WHERE history and duration of hypertension, since when certified by the treating Doctor supported by the first consultation paper. The complainant in his evidence in chief in para-8 has specifically stated that after receipt of the relevant documents, the OPs did not take any steps for early release of the claim amount. No rebuttal counter affidavit has been filed by the OPs, even though copy thereof was served on them through their advocate on 17.07.2021. So the evidence adduced by the complainant stands uncontroverted.
- That as the evidence adduced by the complainant stood uncontroverted and all the relevant documents are placed before this Commission we are of the opinion that the petitioner has supplied relevant documents to the OPs. Since the dispute is only related to non-submission of documents and as the occurrence treatment in the two hospitals and discharge certificates are not disputed by the OPs there is no doubt that the complainant is entitled to get the insurance claim to the extent as per the terms and conditions of the policy. Therefore, we feel that there is a gap of communication between the complainant and the OPs which has resulted in repudiation of the claim and hence the order.
ORDER
The complaint petition is allowed in part against the OPs.The OPs are directed to intimate the petitioner which documents they require for processing the claim within a period of 10days from the date of receipt of this order and the complainant is directed to furnish all the required documents within a month from the date of receipt of the intimation from the insurance company and in the event of any delay, the OPs shall have to pay penalty of Rs.1000 daily to the petitioner from the last date fixed by this Commission till the order is complied. It is made clear that the OPs cannot ask for any other new document except those they have called for from the complainant. In the peculiar facts and circumstances of the case parties to bear their own cost. The case is accordingly disposed off.
I Agree
PRESIDENT MEMBER
Pronounced in the open Commissioner today on this 30th day of June 2022 in the presence of the parties.
PRESIDENT MEMBER
