Orissa

Cuttak

CC/59/2022

Dr Nirmal Garabadu - Complainant(s)

Versus

Director,Manipal Signa Health Insurance Co Ltd - Opp.Party(s)

R K Pattanaik & associates

10 Nov 2022

ORDER

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

                                        C.C.No.59/2022

 

Dr. Nirmal Garabadu,

S/O:Late Trilochan Garabadu,

At:Health Care,Mahatab Road,

At/PO/Dist:Cuttack-753001,Odisha.                                                        ... Complainant.

 

                                                Vrs.

1.        The Chairman Cum Managing Director,

       Manipal Cigna Pro Health Insurance Co. Ltd.,

Regd. Office:401/402,43th Floor,Raheja Titanium,

Off Western Express Highway,Goregaon(East),

Mumbai-400063,India

 

2.        Branch Manager,                                                     

Policy Servicing Office,

Manipal Cigna Pro Health Insurance Co. Ltd.,

Unit No.18,4^th Floor,Chowringhee Court,

55, Chowringhee Road,Kolkata-700071,

West Bengal,India.

 

3.      Branch Manager,                                                     

Manipal Cigna Pro Health Insurance Co. Ltd.,

Room No.13,2^nd Floor,Deendayal Bhawan,

Ashok Nagar,Unit-II,Bhubaneswar-751009,   

Dist-Khurda                                                                             ... Opp. Parties.

 

 

Present:               Sri Debasish Nayak,President.

                                Sri Sibananda Mohanty,Member.

 

Date of filing:     06.04.2022

Date of Order:   10.11.2022

 

For the complainant:          Mr. R.K.Pattnaik,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 the complainant alongwith his wife had taken a policy from the O.Ps in order to protect themselves from their health hazards.    The said policy bearing no.PROHLR010125762 under name and style “Manipal Cigna Pro Health Insurance” was effective from 6.6.20 to 5.6.21 for which a premium of Rs.40,183.93 was paid and the assured sum for the said policy was of Rs.4,50,000/-.  The complainant had gone to Apollo Hospital,Bhubaneswar on 5.10.20 where he was diagnosed of HTN,CKD,Covid-19 Pneumonia and Hypothyroidism.  He was admitted that day as an indoor patient and was discharged on 18.10.20 after treatment.  The Apollo Hospital authorities had raised a bill of Rs.2,43,365/-  but the O.Ps had approved payment of Rs.1,38,316/- only for which the complainant had to bear the balance amount of Rs.1,05,049/- from his own pocket.  That apart he had spent a sum of Rs.14,859/- on 20.1.21 as regards to some other tests.

            On 15.2.22 the complainant sustained acute chest pain with head-reeling alongwith weakness and hypertension for which he was again hospitalised at Shanti Memorial Hospital of Cuttack on  16.2.22 and was diagnosed of HTM,CKD on HD, Pre-syncope, Sinus Bradycardia, Holter  Normal and was treated for two days there by spending Rs.27,343/-.   On making claim, the O.Ps through their TPA vide M/s. Medi Assist Insurance TPA Pvt. Ltd. had intimated the complainant through their letter dt.17.2.22 that the complainant had suppressed the fact that he was suffering from CKD since 2015 and had not disclosed the same in his proposal form dt.7.6.16.  Accordingly the claim of the complainant was repudiated by the O.Ps.  The complainant through his complaint petition has objected to the reason of repudiation as made by the O.Ps and had urged that while being treated at Apollo Hospital, the O.Ps had made payment for his treatment there and there was no such objection which they subsequently have made without any basis.  Thus, the complainant has filed this case claiming a sum of Rs.34,459/- towards his medi-claim policy from the O.Ps which were paid by him at the hospital while he was being treated.  He had also claimed from the O.Ps a sum of R.1,00,000/- towards compensation for his mental agony and harassment and a sum of Rs.20,000/- towards his litigation expenses.

            The complainant has filed copies of series of documents in order to establish his claim.

2.         Having not contested this case, the O.Ps are set exparte vide order dt.10.6.2022.

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

i.          Whether the case of the complainant is maintainable ?

            ii.         Whether the O.Ps were deficient in their service ?

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

            From the averments as made by the complainant in his complaint petition together with the supportive documents whose copies are filed by the complainant alongwith his complaint petition when perused, it is noticed that infact the complainant had taken one Manipal Cigna Pro Health Insurance policy from the O.Ps by paying the premium and when the said policy was in force with effect from 6.6.2021 to 5.6.2022, the complainant had undergone treatment for the second time with effect from 16.2.2022.  The reason of repudiation of the claim of the complainant by the O.Ps, appears to be without any basis or having any valid reason.  Thus, there was infact deficiency in service by the O.Ps here in this case when they had repudiated the claim of the complainant without any reason.  Accordingly, the case of the complainant is maintainable and he is entitled to the reliefs as claimed by him.  Hence it is so ordered;

 

                                                             ORDER          

            The case is allowed exparte against the O.Ps.  The O.Ps are found to be jointly and severally liable here in this case.  The O.Ps are thus directed to settle the medi-claim of the complainant to the tune of Rs.34,459/- alongwith interest thereon @ 12% per annum with effect from 187.2.2022 till the total amount is quantified.  The O.Ps are further directed to pay a sum of Rs.1,00,000/- to the complainant towards his mental agony and harassment and also to pay a sum of Rs.20,000/- towards his litigation expenses within a period of 30 days from the date of receipt of copy of this order.

Order pronounced in the open court on the 10^th day of   November,2022 under the seal and signature of this Commission.           

                                                                                                                                Sri Debasish Nayak

                                                                                                                                            President

                       

                                                                                                                                                               Sri Sibananda Mohanty

                                                                                                                                               Member