Orissa

Cuttak

CC/111/2023

Debasish Parida - Complainant(s)

Versus

HDFC Ergo General Insurance Company Ltd - Opp.Party(s)

R K Pattanaik & associates

08 Aug 2024

ORDER

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

C.C.No.111/2023

Debashish Parida.

S/o: Purna Chandra Parida,

At:Mundamunana,P.O:Pobrahmanigaon,

P.S:Barang,Dist:Cuttack.                                                 ... Complainant.

 

          Vrs.

 

HDFC ERGO General Insurance Company Ltd.,

                 At:1st Floor,HDFC House,165-166

Backbay Reclamation,H.T.Parekh Marg,

                Churchgate,Mumbai-400020.                                       ...Opp.Party

 

Present:         Sri Debasish Nayak,President.

                      Sri Sibananda Mohanty,Member.

 

Date of filing:    12.04.2023

Date of Order:  08.08.2024

 

For the complainant:             Mr. Chinmaya Mohanty,Adv. & Associates.

For the O.P                :             Mr. S.K.Ruplal,Advocate.

 

Sri Debasish Nayak,President

Case of the complainant as made out from the complaint petition in short is that he had obtained one Optima Restore Individual Insurance policy from the O.P on 11.11.2015 vide policy number 2805203816073702000 which was being renewed from time to time.  In the month of December,2015, the complainant was detected with chronic kidney disease for which he was hospitalised at Kalinga Hospital of Bhubaneswar on 1.1.2016 for transplantation of his kidney.  He had putforth his claim before the O.P which was also settled in the month of October,2016.  Subsequently after kidney transplantation, the complainant was time and again being admitted to the hospital due to post kidney transplantation complications like Diabetes, Hepatitis-C etc and all these treatments were paid in cashless mode.  During pre-hospitalisation for a period of 80 days and for post-hospitalisation for a period of 180 days the complainant had claimed reimbursement which was also duly reimbursed to him and thereafter he was admitted again to the hospital due to heart palpitation.  In the said case, an amount of Rs.25,000/- was approved by the O.P in his favour.  The hospital had wrongly submitted about the complainant to be suffering from cardiac problem but subsequently it was rectified that the complainant was having heart palpitation due to several medications.  The hospital had raised a bill of Rs.1,20,000/- but when such amount was claimed by the complainant, the O.P had rejected such claim and had asked the complainant to pay back the money and accordingly the complainant had issued a blank cheque. 

The complainant was again hospitalised at Appollo Hospital of Bhubaneswar and was under the treatment of Dr. Nisith Mohanty, Nephrologist.  There the complainant had raised a claim of Rs.1,80,000/- for his pre-hospitalisation period of 60 days and post-hospitalisation period of 180 days but without settling his said claim, nine months thereafter, the O.P has threatened the complainant to cancel the policy as issued in his favour.   Subsequently, all his medical expenses were borne by him without being reimbursed by the O.P.  The complainant was admitted at AMRI Hospital for treatment of Hepatitis-C in the month of November,2022 where a claim of Rs.1,66,000/- was raised but the O.P has not reimbursed the said amount.  Rather, on 14.3.2023 the O.P had issued a letter to the complainant intimating him about the repudiation of his claim on the ground of fraud.  He was threatened in the said letter to cancel his policy on the ground of fraud, misrepresentation and non-disclosure of material facts etc.  Thus, the complainant has come up with his petition before this Commission claiming a sum of Rs.1,66,000/- to be reimbursed by the O.P towards his medical expenses as incurred by him together with compensation to him with a sum of Rs.50,000/- towards his mental torture, physical harassment and financial loss and he has further prayed for a sum of Rs.15,000/- towards cost of his litigation.  He has also prayed for any other order as deemed fit and proper.

Together with his complaint petition, the complainant has annexed copies of certain documents in order to prove his case.

2.       The O.P has contested this case and has filed his written version wherein it is mentioned that the case of the complainant is not maintainable which is liable to be dismissed with cost.  It is alleged that the complainant had suppressed the material facts.  The O.P admits about the complainant to have obtained Optima Restore Individual Insurance policy from the O.P vide number 2805203816073702000 which was effective from 10.11.2022 to 9.11.2023 subject to certain terms and conditions therein.  The O.P received a claim intimation from the complainant vide claim I.D RC-HS22-13332810 for cashless facility towards treatment of the complainant and hospitalisation from 12.12.2022 to 14.12.2022 at AMRI Hospital and the same was also approved.  The final bill of Rs.31,546/- was approved and a settlement letter to that effect dated 27.12.2022 was also issued to him. Thus, the complainant was paid a sum of Rs.29,443/- after the compulsory deductibles.  Subsequently, the complainant had raised claim for his pre & post-hospitalisation expenses which was registered vide ID number RC-HS22-13332810-1 & ID number RC-HS22-13332810-2.  After processing those bills, settlement letter dt.6.1.2023 was issued to the complainant but the bills/invoices issued from Yashika Medical in favour of the complainant were found to have been issued without any GST number/Bar code and those were also found to be highly inflated bills.  In this connection effort was made to contact the complainant but he had not cooperated and when the O.P through his agent had tried to contact the said Yashika Medical, the contact number available of the said medicine store was found to be invalid nor could such Pharmacy be traced which clearly signified practice of fraud by the complainant.  Accordingly, letters were issued to the complainant on 13.3.23 and 14.3.23.  The O.P in this context has relied upon the case of Ravneet Singh Bagga Vs. KLM Dutch Airlines (2000) 1 SCC 66 wherein the Hon’ble Supreme Court has held that “the test of deficiency in service lay in the complainant proving that there was some fault imperfection, shortcoming or inadequacy in the manner of the Insurance Company and further such fault etc must be wilful. More importantly the Hon’ble Supreme Court has held that where there is a bonafide dispute between parties and where the service provider has after considering all the material with them and the relevant facts has acted in a particular manner, then such acts will not amount to deficiency in service.”  Accordingly, it is prayed by the O.P to dismiss the complaint petition as filed by the complainant which is based on frivolous and vexatious allegations.

          The O.P has also filed copies of several documents alongwith the written version in order to prove it’s stand.

3.       Keeping in mind the averments as made in the complaint petition and the contents of the written version of the O.P, 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 is any deficiency in service on the part of the O.P?

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.

On perusal of the complaint petition, written version, written notes of submission as filed from both the sides as well as the copies of documents available in the case record, it is noticed that the complainant had infact obtained Optima Restore Individual Insurance policy from the O.P which was in force while he was ill and was hospitalised.  On perusal of the copies of documents as annexed by the complainant together with his complaint petition at page number 11,12 & 13 that those were bills regarding payment of the medicines etc bought from Yashika Medicine on 10.11.22 and 14.12.22.  The contention of the O.P for the said medicine bills as procured by the complainant from Yashika Medicine store were highly inflated, were having no GST and Bar code. They had tried to contact the complainant in that regard but the complainant had not cooperated and had rather remained silent.  Subsequently, the O.P through it’s agent had tried to contact the said Yashika medicine store and they could know that the available contact numbers were invalid and there was also no such Pharmacy.  In that context they had sent letters to the complainant alleging practice of fraud and show-cause as to why the policy as issued in his favour would not be terminated.  The complainant has filed copy of the said letter of the O.P dated 14.3.23 alongwith his complaint petition.  While analysing the several copies of documents as annexed by the O.P here in this case alongwith it's written version, it is noticed that undoubtedly there are several claims which have been settled in favour of the complainant but the O.P had suspected the medicine bills of the complainant those he had procured from one Yashika medicine store vide Annexure-J series.  As per Annexure-L, it is noticed that the O.P had requested for the GSTIN number and the actual address of the said Pharmacy suspecting the bills as per Annexure-J series but no response was made by the complainant in that context.  Accordingly, the O.P had issued notice of cancellation to the complainant on 14.3.2023.  The complainant has not whispered a word as regards to those medicine bills which he had produced making his claim in that regard from the O.P.  He has also hot responded to the cancellation notice as issued to him by the O.P on 14.3.23.  Thus, keeping in mind such facts and circumstances of this case and after careful scrutinization of the copies of documents available in the case record, it is noticed that the allegation as made by the complainant against the O.P of this case regarding deficiency in service is not made out.  This issue thus goes against the complainant.

Issues no.i & iii.

          From the discussions as made above, the case of the complainant is not maintainable and the complainant is not entitled to the reliefs as claimed by him.  Hence it is so ordered;

                                              ORDER

          Case is dismissed on contest against the O.P and as regards to the facts and circumstances of the case without any cost.

          Order pronounced in the open court on the 8^th day of August,2024 under the seal and signature of this Commission.                                                                                                               

                                                                     

                                                                                  Sri Debasish Nayak

                                                                                                      President

                                                                                            Sri Sibananda Mohanty

                                                                                                 Member