Sri S.K.Sahoo,President.

          This  is  a petition U/s. 12 of C.P.Act, 1986  filed by the complainant   Alka Rani  Singh against the opp.parties.

2.       The  case of the  complainant  is that being  influenced  by the  Area Manager and  the agent of the opp.parties   of the Insurance  Company  she insured  herself under  the company’s  of the  opp.parties. The  complainant  deposited  an amount  of  Rs.5,890.00 on 21.08.2015 towards premium  and  opened  a policy bearing No. 2825/55383356/00/00 with the  opp.parties. The  certificate  of  family floater plan insurance has been issued in  favour of the  complainant  by the opp.parties on 31.08.2015. The opp.parties’ company has also issued  a  cash less facilities card  in favour  of the  complainant , which is  to be  utilised  in case of  need for   hospitalization  support. On 14.02.2016  the  complainant  felt  pain in her stomach  and  immediately  consulted the  doctor  at Balhar Chawk, Talcher  and  went to  Sparse Hospital  and  Critical Care Pvt. Ltd. situated at Saheednagar ,Bhubaneswar for better treatment where  she  was admitted  on 15.02.2016 .During her  treatment  she  requested  for  cashless facility  and  his  claim bearing No.  100021620115 for  hospitalization  under the  said policy on 17.02.2016 .The opp.parties  refused to provide  cashless  facilities ,for which the  complainant  obtained  private loan  from  his relatives  and paid  the medical  bills  of  Rs.50,000.00 to the  hospital authority on 18.02.2016 . The    refusal of   extension of  cashless  treatment  facilities to the  complainant  by the opp.parties  is   gross deficiency  in their  service. Hence  this case.

3.       Notice  was issued to  both the opp.parties through Regd. post with A.D on 21.07.2016 . In pursuance  to  such  notice  the  Mr. Piyush Sharkar the then Asst. General Manager  of the opp.parties’ company appeared  through Learned Counsel Mr. J.N.Mishra and  S.C.Behera and submitted  his  written statement . The  case  of the  opp.parties is that the  case is not maintainable in the eye of law. The  complainant  is not  a consumer .There is  no  cause of  action to file this  complaint. The  complainant  has not impleaded  (EMSL) E-meditek (TPA) service  Ltd. who  is  a necessary  party in this  case. The  claim of the  complainant is bad  for  mis-joinder and non-joinder of necessary party. Admittedly the  company of the opp.parties’ has  issued  a policy to the  complainant  on 21.08.2015  subject to the terms and conditions,  limitation and  exclusion of the  policy. It  reveals  from  paragraph- 6  of the  complaint petition that the petitioner  was admitted  in  Spars  and Critical Care Pvt. Ltd.  on 15.02.2016 i.e  within  one year  from  inception of the  policy.  After receiving the information the E-meditek  (TPA) services ltd. immediately  intimated  the authority of  Spars Hospital  and  Critical care Pvt. ltd. vide  letter dtd.18.02.2016  not  to extend the  cashless  facility  to the  complainant, in view of   the terms and  conditions mentioned under  exclusion clause of  policy condition. The  hospital  was requested to  collect the  expenses  from the  complainant . However the  complainant may submit the hospitalization paper  for  reimbursement  as  per  the policy terms  and  condition .From the medical papers  it  reveals  that  the complainant has  under gone  “lap myomectomy”  and the said  disease  has  one year  waiting period  from the  date  of  inception of the  policy under  exclusion clause. The  E-meditek (TPA) services Ltd. with  due application of  mind has  rightly rejected   the claim  of  cashless  facilities to the  complainant. It   was duly  intimated to the  hospital concerned  vide  letter  dtd. 18.02.2016 . The  opp.parties are  not  liable to pay any amount  to the  complainant  as  there  is  no  deficiency in service. The  complaint  be  dismissed.

4.       The Learned  Counsel for the opp.parties has filed a written argument  in which he  has relied on the pronouncement of different Hon’ble Courts.

5.       The   complaint  filed    by the  complainant is supported  with  an affidavit. Admittedly  the  complainant has  paid  an amount of  Rs.5,890.00 on 21.08.2015 as premium to the  company of the opp.parties  and  a  policy  bearing No.2825/55383356/00/000 was issued  in her favour and  a certificate of  family  floater plan  insurance  has been issued   to her  on 31.08.2015 by the opp.parties. The  photo  copy of  the   complete  health care  insurance of  the opp.parties  is  available on the  case record. The   letters  used  by the opp.parties  in the  said  document is  very  small  and  it  cannot be read by normal human being. The  company  adopts  unfair  trade practice  by using  such tiny letters in the insurance policy. On perusal of  the   front page of the  policy issued in favour of the  complainant it is clear that the  exclusion:-NA (not  applicable). It  also appears that the  company  of the opp.parties has not  communicated  the  exclusion clause  in the  policy issued  in favour  of the  complainant. The  onus is  on the  opp.parties to prove  that  they have communicated the  terms and conditions of  the  exclusion clause of the  policy  while  it was  issued to the complainant. The opp.parties  utterly failed   to prove that the  exclusion clause of the  policy  was  duly  communicated  to the  complainant at the time of issuance of policy  and  she has signed the  documents being   conscious about the  terms and  conditions of the policy if  any .So the   refusal  of  cashless  treatment  to the complainant is nothing  but gross negligence on the  part of the opp.parties.

6.       The  complainant  is  admittedly  is  a consumer as  she has paid  the   premium  to  get  cashless service  towards her  treatment. There is  also  cause  of action to  file  this case as the opp.parties  refused  to pay  the  money  spent  by the  complainant  towards her  treatment  by the  doctor during her hospitalization. From the documents filed  by the  complainant  it  appears   that she  had spent  an  amount of Rs.50,000.00 towards her  treatment in Spars Hospital & Critical care Ltd., Saheednagar, Bhubaneswar. The opp.parties  were/are bound  to  pay  the said  amount to the  hospital for  cashless  treatment of the  complainant. The  refusal  of  cashless  treatment   of the  complainant by the opp.parties  caused  in convenience, loss, mental agony and  harassment. So there  is  deficiency  in service  by the opp.parties.

7.       Hence  order :-

: O R D E R :

          The case be and the same  is allowed in part  on contest against  both  the  opp.parties. The opp.parties  are directed to pay an amount of  Rs.50,000.00 (Rupees Fifty Thousand) only along  with  interest @ 9% p.a to the  complainant from 18.02.2016 till payment is made. They are further directed to  pay an amount of  Rs.35,000.00 (Rupees Thirty-Five Thousand) only towards  compensation for  mental agony, harassment deficiency in service etc. and Rs.15,000.00 (Rupees Fifteen Thousand) only towards litigation cost.  They are  jointly  and severally liable. The opp.parties are   directed to pay the  aforesaid amounts (Rs.50,000.00 along with interest @9%  per annum from 18.02.2016 till payment  I made + Rs.35,000.00 +Rs.15,000.00 ) to the complainant within a period of  one month from the date  of receipt of this order, failing which  they have  to pay penal   interest @ 12% pa.  from date of default  till payment  is made.