Orissa

Cuttak

CC/306/2023

Akhaya Kumar Behera - Complainant(s)

Versus

LIC Of India - Opp.Party(s)

12 Aug 2024

ORDER

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

C.C.No.306/2023

Akhaya Kumar Behera,

S/o: Late Panchanan Behera,

Residing At: Balabhadrapur,P.O:Mahana,

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

 

          Vrs.

 

Branch Manager,

L.I.C of India, Divisional Office,

PB No.36, Cuttack-1, Dist:Cuttack,

Having it’s Branch Office At:Sikharpur,

P.O:College Square,Dist:Cuttck.                         ...Opp. Party.

 

Present:         Sri Debasish Nayak,President.

                      Sri Sibananda Mohanty,Member.

 

Date of filing:    12.09.2023

Date of Order:  12.08.2024

 

For the complainant:             Mr. B.S.Das,Adv. & Associates.

For the O.P                :             Mr. S.Swain,Advocate.

 

Sri Debasish Nayak,President

Case of the complainant as made out from the complaint petition in short is that the complainant and his son were insured with Jeevan Arogya vide Policy No. 596683520 through the O.P which was effective from 19.2.2015 to 19.2.2025.  Soumya Ranjan Behera, the son of the complainant had fallen down from his motorcycle at Balabhadrapur area of Salepur on 21.1.2023 at 6.00p.m and had thereby sustained injuries.  He was admitted at Shanti Memorial Hospital of Cuttack that day where it was diagnosed that he had sustained fracture of his right Intercondylar Humerus HTN.  He had undergone surgery there on 25.1.23 for the said fracture and was discharged from the said hospital on 29.1.23.  The total amount of Rs.1,40,448/- was incurred there towards the hospitalisation and medication expenses which were paid by the complainant.  On 13.3.23 the complainant had intimated the O.P and had putforth his claim but it was rejected by the O.P through letter dated 29.3.23 on the ground that the injuries as sustained by the son of the complainant were all self-afflicted injuries which according to them were the result of attempted suicide and/or the use or misuse of any drugs or alcohol.  Being aggrieved, the complainant has come up with his case before this Commission seeking a sum of Rs.8,00,000/- in total from the O.P towards his medical expenses and compensation.  He has also prayed for any other order as deemed fit and proper.

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

2.       The O.P has contested this case and has filed his written version in this case mentioning therein that the case of the complainant is not maintainable which is liable to be dismissed.  The O.P admits about the Jeevan Arogya Policy No.596683520 issued in favour of the complainant which covers the health issues of the complainant alongwith his wife and son and it was valid from 19.2.2015 to 19.2.2046 for the complainant and his spouse but it was valid from 19.2.2015 to 19.2.2023 for his son.  The claim of the complainant was not considered since it was as per the terms and conditions of the policy at para-9, Exclusions (xi) of Part C as the insured/patient who is the son of the complainant had taken alcohol at the time of the accident and accordingly letter of repudiation was sent to the complainant on 29.3.2023.  Thus, it is prayed by the O.P to dismiss the complaint petition which is devoid of any merit.

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

          The complainant Akshaya Kumar Behera as well as his son Soumya Ranjan Behera have filed their evidence affidavits in this case but the contents of those evidence affidavits of both father and son when perused, those are noticed to be reiterations of the contents of the complaint petition.

          Similarly, the O.P has filed evidence affidavit through one Sukumar Roy serving as Manager (L & HPF) and the contents of the said evidence affidavit of Sri Sukumar Roy also appears to be a reiteration of the contents of the written version of the O.P.

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 submissions as filed from both the sides, evidence affidavit filed by both the parties as well as the copies of documents available in the case record, it is noticed that infact the complainant had obtained Jeevan Arogya vide Policy for himself, his wife and his son Soumya Ranjan Behera which was in force.  On 21.1.23 at 6.00 p.m while riding motorcycle, the son of the complainant had fallen down at Balabhadrapur area of Salepur for which he had sustained fracture and was admitted that day at Shanti Memorial Hospital of Cuttack where he had undergone surgery on 25.1.2023 and was discharged from the said hospital on 29.1.23.  The claim of the medical expenses which was of Rs.1,40,448/- when putforth by the complainant on 13.3.23 before the O.P, the same was rejected by the O.P on 29.3.23 and it was communicated to the complainant that the repudiation was on the ground that the injuries as sustained by the son of the complainant were all self-inflicted and the insured son of the complainant had used or misused drugs or alcohol.  In this context the O.P alongwith it’s written version has filed Annexure-C/1, which is a copy of the Claim Investigation Report, wherein it is mentioned at Part-B that “Yes alcohol bear at the time of accident” and it was investigated for the insured Soumya Ranjan Behera against policy no. 596683520.  Basing upon such investigation report, the claim of the complainant was repudiated by the O.P. 

But quite strangely during the course of the trial of this case, the complainant has filed a copy of a medical report issued by the Medical Officer of the said Shanti Memorial Hospital of Cuttack vide Annexure-E/1 wherein it is mentioned that “patient named Soumya Ranjan Jena a case of RTA with Right Intercondylar fracture humerus.  The patient had a history of fall from bike due to sudden entry of bear leading to fracture.  Patient was not under the influence of Alcohol.  It was mistakenly written for which we don’t want the patient to suffer, kindly consider the case for which we shall be obliged and patient will be benefited.”  Since when the Medical Officer of the said Shanti Memorial Hospital of Cuttack has provided such a report in favour of Soumya Ranjan Behera who is  the son of the complainant and  also the insured claimant of this case, it is not understood as to wherefrom the O.P could gather through their investigation report that there was influence of alcohol noticed on the part of the said insured/patient Soumya Ranjan Behera,  That apart, while scrutinising Annexure-2 which is a copy of the discharge summary issued by the said  Shanti Memorial Hospital Pvt. Ltd., in favour of the Soumya Ranjan Behera, the son of Akhaya Kumar Behera the complainant of this case, it is noticed that nowhere it is mentioned that the patient when came to be  admitted in the said hospital, was under the influence of alcohol.  Thus, the repudiation of the bonafide claim of the complainant as made by the O.P here in this case appears to be unilateral, ingenuine and arbitrary.  Keeping such facts and circumstances of this case in mind, when the bonafide claim of the complainant has been repudiated by the O.P on flimsy grounds, the allegation as made by the complainant against the O.P that there was deficiency in service by the O.P appears to be correct.  This issue thus, goes in favour of the complainant.

Issues no.i & iii.

From the discussions as made above, the case of the complainant is definitely maintainable and he is thus entitled to the reliefs as claimed by him from the O.P here in this case.  Hence it is so ordered;

ORDER

The case is decreed on contest against the O.P.  The O.P is thus directed to reimburse the claim amount of the complainant i.e. Rs.1,40,448/- together with interest thereon @ 12% with effect from 29.3.2023 till the total amount is quantified.  The O.P is further directed to pay the complainant an amount of Rs.1,00,000/- as compensation for his mental agony and harassment as well as towards his litigation expenses.  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 12^th day of August,2024 under the seal and signature of this Commission.         

                                                                                      

                                                                                      Sri Debasish Nayak

                                                                                              President

 

 

                                                                                          Sri Sibananda Mohanty

                                                                                                      Member