Orissa

Cuttak

CC/183/2022

Sudhansu Sekhar Choudhury - Complainant(s)

Versus

Chief Managing Director,Care Health Insurance Ltd - Opp.Party(s)

B C Ghadei & associates

28 Mar 2024

ORDER

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

C.C.No.183/2022

 

Sudhansu Sekhar Choudhury,

S/o: Late Upendranath Swain,

Resident of At:Plot No.833,

Industrial Area,Ganapati Plaza,

Khapuria(Nadikula),

P.S:Madhupatna,Dist:Cuttack,

Pin-0753010.                                                                                ... Complainant.

 

          Vrs.

 

1.       Care Health Insurance Limited

(formerly known as Religare Health Insurance Co. Ltd.,),

Regd. Office at 5^th Floor,19, Chawla House,

Nehru Place,New Delhi-110019,

Corporate Office:Unit No.604-607,

                   6^th floor,Tower-C,Unitech Cyber Park,

                   Sector-39,Gurugram-122001(Haryana)

​                  IRDA Regd. No.148,(IN:U6600ODL2007PLC161503),

Represented through its Chief Managing Director.

 

2.        Authorised Officer, Care Health Insurance Limited

(formerly known as Religare Health Insurance Co. Ltd.,),

Regd. Office at 5^th Floor,19, Chawla House,

Nehru Place,New Delhi-110019,

Corporate Office:Unit No.604-607,

                     6^th floor,Tower-C,Unitech Cyber Park,

                   Sector-39,Gurugram-122001(Haryana)                             ...Opp.Parties

 

Present:         Sri Debasish Nayak,President.

                      Sri Sibananda Mohanty,Member.

 

Date of filing:    12.09.2022

Date of Order:  28.03.2024

 

For the complainant:          Mr. B.C.Ghadei,Adv. & Associates.

For the O.Ps                :         Mr. R.Pati,Adv. & Associates.

 

 

 

Sri Debasish Nayak,President                   

Case of the complainant as made out from the complaint petition in short is that he had obtained a Health Insurance Policy from the O.Ps on 20.11.2020 with policy bearing no.16033126.  The said policy was valid upto 19.11.2021 and it was covering the health issues of the complainant as well as that of his wife.  The complainant had paid the premium of Rs.58,000/- towards such policy.  As because the complainant fell ill having some serious health issues, he was admitted to the Apollo Hospital,Bhubaneswar on 16.5.2021 and was treated there upto 20.5.2021 when he was discharged.  The medical expenses as incurred there towards the treatment of the complainant was of Rs.1,17,000/-.  The complainant had made the claim for the said amount from the O.Ps since because he had his health insurance policy.  But the O.Ps had repudiated the claim of the complainant through their letter dt.25.10.2021 for which the complainant has come up with this case before this Commission seeking direction to the O.Ps to provide him the benefits of his health insurance as per the terms and conditions of his policy and also to pay compensation to him of Rs.3,00,000/- towards his mental agony and harassment.  He has further prayed to direct the O.Ps in order to pay another sum of Rs.15,000/- towards his litigation expenses. 

          Alongwith his complaint petition, the complainant has annexed copies of several documents in order to prove his case.

2.         Both the O.Ps have contested this case and have jointly filed their written version through which they have urged that the case of the complainant is not maintainable which is liable to be dismissed with cost.  According to them, the complainant has filed this case with an oblique motive only.  They admit about the health insurance policy plan namely “CARE Floater” as obtained by the complainant Sudhansu Sekhar Choudhury through policy no.16033126 which was covering the health issues of the complainant as well as his spouse Jyotsna Mayee Choudhury.  The said policy was effective from 18.10.2019 to 17.10.2020 initially with an assured sum of Rs.5,00,000/- and after being renewed it became effective from 20.11.2020 to 19.11.2021. Again being renewed, it was effective from 28.11.2021 to 19.11.2022.  As per the discharge summary, the complainant was diagnosed with DM,HTN,Hyponatremia,seizures,Old LT Tiba operated.  According to the O.Ps, as per the history sheet of Apollo Hospital dated 16.5.2021 the complainant was having history of diabetes and hypertension.  Thus, they wanted exact duration of the past history of the present ailment with first consultation paper and all past treatment records for DM, HTN and Seizures, Pre-Hospitalisation OPD Treatment Record, Complete Indoor Case Papers with Admission Notes, History Sheet, Doctor’s Notes, Nursing Notes and Vital Chart from the complainant. But since because the complainant had not sent any reply, they had issued reminders to him dated 27.7.2021 and 3.8.2021 and since because the complainant had miserably failed to reply to such queries as raised, the claim as made by the complainant was closed which was communicated to the complainant through their letter dated 25.10.2021.  Accordingly, it is prayed by the O.Ps through their written version to dismiss the complaint petition as filed by the complainant with cost.

          Together with the written version, the O.Ps have filed copies of several documents in order to prove their stand as taken by them.

          The O.Ps have also filed evidence affidavit through one Parth Arora working as Manager, Legal in their insurance company but the contents of the evidence affidavit of the said Parth Arora when perused it is noticed to be a reiteration of the averments as made by the O.Ps in their written version.

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, the written version, written notes of submissions from either sides, evidence affidavit as filed by the O.Ps as well as the copies of documents available in the case record, it is noticed that infact the complainant had availed “CARE Floater” Health Insurance Policy no.16033126 which was valid when he fell ill and was admitted to the Apollo Hospital at Bhubaneswar for treatment from 16.5.2021 to 20.5.2021.  It is also not in dispute that at the Apollo Hospital the bill raised towards the treatment of the complainant was of Rs.1,17,000/- and that the complainant had raised his claim to avail the benefits of the Health Insurance Policy as obtained by him from the O.Ps. The O.Ps through their letter dated 25.10.2021 had repudiated the claim of the complainant on the ground that the complainant had past history of diabetes and hypertension which they could know from the discharge summary of the complainant as issued by the Apollo Hospital authorities.  But on careful scrutiny of the discharge summary of the Apollo hospital, copy of which is available in the case record, it is noticed that no where it is mentioned therein that the complainant had any past history of diabetes or hypertension.  It is not understood as to wherefrom the O.Ps could get such past history to repudiate the claim of the complainant. Moreso, according to the O.Ps, they had issued two reminder letters to the complainant asking him to provide them the details of his past history of such illness and treatment that effect to which the complainant had not replied rather had remained silent.  While verifying the copies of documents as made available here in this case record, being submitted by the O.Ps, it is noticed that they had issued a letter dt.20.7.2021 to the complainant asking him to provide additional informations in order to process his claim.  Again on 27.7.2021 and on 3. 8.2021, the O.Ps had issued reminders to the complainant asking for the additional informations as required by them and according to them, the complainant had not responded to such demand of documents as made by them.  Quite interestingly though such copies of letters are available in the case record being submitted by the O.Ps, the O.Ps have failed to prove through any cogent evidence that if such letters were really issued by them and were sent and received by the complainant, since because no such postal receipt is affixed or produced by the O.Ps to that effect.  Thus, considering the facts and circumstances of this case, this Commission comes to an irresistible conclusion that infact the O.Ps had whimsically, arbitrarily and unilaterally repudiated the genuine claim of the complainant without having any basis which clearly indicates deficiency in their service as well as practice of unfair trade by them.  Hence, this issue goes in favour of the complainant.

 

 

Issues no.i & iii.

From the discussions as made above, the case of the complainant is undoubtedly maintainable and the complainant is entitled to the reliefs as claimed by him.

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 provide the health insurance benefits as per the terms and conditions of the policy no.16033126 to the complainant with immediate effect.  The O.Ps are also directed to pay a sum of Rs.3,00,000/- towards compensation to the complainant for causing mental agony and harassment to him and further to pay another sum of Rs.15,000/- towards the litigation expenses of the complainant.  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 28^th day of March,2024 under the seal and signature of this Commission.                                                                

                                                                                      

                                                                                      Sri Debasish Nayak

                                                                                              President

 

 

                                                                                          Sri Sibananda Mohanty

                                                                                                      Member