Orissa

Cuttak

CC/182/2022

Debasish Rout - Complainant(s)

Versus

Claims Department, Future Generali Health (FGH) Future Generali India Insurance Company Ltd - Opp.Party(s)

U R Jena & associates

14 Aug 2023

ORDER

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

C.C.No.182/2022

 

          Debasish Rout,

           Plot No.60,At:Mahanadi Vihar,

           P.O:Naya Bazar,Dist:Cuttack,

           PIN-753004,Odisha.                                                       ... Complainant.

 

          Vrs.

 

1.       Claims Department

Future Generali Health (FGH),

Future Generali India Insurance Company Ltd.,

Office No.3,3^rd Floor, Building A,

G-O-Square,Sr. No.249+250,

Near Mankar Chowk,Aundh Hinjewadi Link Road,

Wakad Pune,Maharashtra-411057.

 

2.       Channel Development Manager-Rural Insurance,

Future Generali India Insurance Company Ltd.,

Off Code-48,2^nd Floor,Kalinga Complex,

Plot No.B,Unit-1,Rajpath,Bhubaneswar,

                  Odisha-751009                                                                   ...OPP. Parties

 

 

Present:         Sri Debasish Nayak,President.

                      Sri Sibananda Mohanty,Member.

 

Date of filing:   12.09.2022

Date of Order:  14.08.2023

 

For the complainant       :          Mr. U.R.Jena,Adv. & Associates.

For the O.Ps                      :                     None.

 

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 called “Corona Rakshak” from the O.Ps bearing policy no.CRP-48-20-7511354-00-000 which was effective from 27.7.2020 till the midnight of 7.5.2021.  To that effect the complainant had paid premium of Rs.1273/- to the O.Ps.  The assured amount was of Rs.2,50,000/- with no pre-existing condition.  On 26.9.2020 the complainant was detected Covid positive and as per the advise of the doctor he had to undergo medical treatment at SUN Hospital at Cuttack being admitted.   He was discharged from the said hospital on 30.10.2020 after being admitted as a patient with effect from 27.9.2020 and was under the treatment of Dr. Chandan Sinha there.  After being discharged, he had claimed for reimbursement of the medical expenses from the O.Ps as incurred by him by submitting all the necessary medical documents.   But the O.Ps had remained silent even if the complainant had sent repeated reminders to them for clearing his claim amount.  He had ultimately issued legal notice to the O.Ps on 21.6.2021 and having no other way out he had to take recourse before this Commission praying for the total claim amount of Rs.2,50,000/- from the O.Ps alongwith interest thereon @ 12% per annum.  He has also sought for bonus of 10% from the O.Ps and has further claimed a sum of Rs.5,00,000/- from the O.Ps towards compensation for his mental agony and harassment.  He has further prayed for a sum of Rs.20,000/- towards his litigations expenses besides, has also prayed for any other relief as deemed fit and proper.

          Alongwith his complaint petition, he has filed copies of several documents in order to prove his case.

2.       Having not preferred to contest this case, the O.Ps have been set exparte vide order dated 15.11.2022.

3.       The points for determination in this case are as follows:

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?

Point No.ii.

Out of the three points, point no.ii being the most pertinent one is taken up first for consideration here in this case.

After perusing the complaint petition and the copies of several documents as annexed here in this case, being provided by the complainant, it is noticed that in fact the complainant had a Corona Rakshak Policy with assured amount of Rs.2,50,000/- which was effective when he was detected Covid-19 positive and he had undergone treatment as an indoor patient at the SUN Hospital at Cuttack for about a month.  It is also true that after being discharged from the said hospital, he had put forth his medical claim before the O.Ps by submitting the relevant documents to that effect.  He has also sent repeated reminders and ultimately a legal notice to the O.Ps but the O.Ps had not listened to such claim of the complainant even if the policy was effective and the copies of medical documents as available in the case record appear to be genuine.  The O.Ps had arbitrarily and whimsically repudiated the claim of the complainant on 26.7.2021 through copy of their letter to the complainant vide Annexure-4 even though the complainant had furnished all the relevant documents as available with him.  Thus, this Commission comes to a conclusion that infact the O.Ps by not paying any heed to the legitimate medical claim of the complainant are infact found to be negligent in their duties and thus, they can be obviously termed to be deficient in their service who have also practised unfair trade by not settling the medical claim of the complainant even if he had a genuine claim and the insurance policy as availed by him was in force during his hospitalisation as an indoor patient.  Accordingly, this point goes in favour of the complainant.

Points no.i & iii.

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

                                                          ORDER

The case of the complainant is allowed exparte 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 assured claim amount of Rs.2,50,000/- to the complainant alongwith interest thereon @ 8% per annum from 23.11.2020 till the amount is quantified.  The O.Ps are also directed to pay the complainant a sum of Rs.1,00,000/- towards compensation for his mental agony and harassment alongwith a sum of Rs.20,000/- towards cost of his litigation.  This order is to be carried out within a period of 30 days from the date of receipt of this order.

Order pronounced in the open court on the 14^th day of   August,2023 under the seal and signature of this Commission.         

                                                                                               Sri Debasish Nayak

                                                                                                      President

                     

                                                                                                              

                                                                                             Sri Sibananda Mohanty

                                                                                                        Member