Orissa

Cuttak

CC/26/2019

Prafulla Kumar Jena - Complainant(s)

Versus

Life Insurance Corporation of India - Opp.Party(s)

R B Mohapatra & associates

18 May 2022

ORDER

 

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

                                                               

                                                            C.C.No.26/2019

1.            Prafulla Kumar Jena,

S/O:Yudhisthir Jena,

At present Res. of Plot No.2E-656,Sector-11,

C.D.A,P.O:Abhinab Bidanasi,

Cuttack-753015,City & Dist:Cuttack(Odisha).                       

 

2.            Krishna Kumari Rout,

W/O:Prafulla Kumar Jena,

At present Res. Of Plot No.2E-656,Sector-11,

C.D.A,P.O:Abhinab Bidanasi,

Cuttack-753015,City & Dist:Cuttack(Odisha).                             ... Complainants.

 

                                                Vrs.

1.        Manager(CRM),

Life Insurance Corporationof India,

Cuttack Division,At:Jeevan Prakash Building,

P.B.No.36,Cuttack-753001,

City & Dist:Cuttack.

 

2.         Manager(CRM),

Life Insurance Corporationof India,

Cuttack Division,At:Jeevan Prakash Building,

P.B.No.36,Cuttack-753001,

City & Dist:Cuttack.

 

3.        Manager(HI),

Life Insurance Corporationof India,

Cuttack Division,At:Jeevan Prakash Building,

P.B.No.36,Cuttack-753001,

              City & Dist:Cuttack .    

 

4.        Branch Manager,

Life Insurance Corporation of India,Cuttack Branch Office,

Shikharpur,Cuttack-753003,

City & Dist:Cuttack

 

5.        Heritage Health Insurance TPA Pvt. Ltd.,

At:NICCO House,5th floor,2 Hare Street,Kolkata-700001.              ... Opp. Parties.

 

 

6.           Sarangi Clinic and Research Centre Pvt. Ltd.

At:Badambadi,represented by its Managing Director,

P.O:Cuttack-753012, City & Dist:Cuttack.                                          ...Proforma O.P.

                       

Present:               Sri Debasish Nayak,President.

                                Sri Sibananda Mohanty,Member.

 

Date of filing:    19.02.2019

Date of Order:  18.05.2022

 

For the complainants            :          Mr. R.B.Mohapatra,Adv. & Associates.

For the O.Ps No.1 to  4          :          Mr. R.K.Pattnaik,Adv. & Associates.

For the O.Ps No.5 & 6            :                       None.

 

Sri Debasish Nayak,President.

 

            The case record is put up today for orders.

            The case of the complainants bereft unnecessary details as made out form the complaint is that the complainant had taken Jeevan  Arogya Policy from the O.Ps covering Health and Life of himself, his wife and his son.  He had paid the first premium on 20.11.2015 by virtue of which the policy of assurance bond was issued to him vide policy No.596955252 with effect from 8.12.2015, and the assured term was of Rs.1,00,000/-.  The complainant had paid the first premium of Rs.9075/- on 20.11.15 and thereafter had renewed the policy by paying the premium of Rs.9114/-, Rs.9352/- and Rs.9351 on 13.12.16, 21.12.17 and 3.12.18 respectively.  While the said policy was in force, the complainant No.2 namely Krishna Kumari Rout was admitted to Sarojini Hospital at Badambadi of Cuttack, vide indoor patient No.267 dt.17.7.18 due to some gynaec problem and heavy bleeding which was diagnosed  “Adennomysis of Uterus”.  The wife of complainant, (complainant no.2) was admitted as an indoor patient from 17.7.18 to 24.7.18 and she had undergone surgery on 20.7.18.  She was in the ICU with effect from 20.7.18 7.00 P.M to 22.7.18 till 2.00 P.M.   The total expenditure of the said period for the complainant no.2 was of Rs.58,616/- for which complainant No.1 had applied to the O.Ps 1,2 & 3 for reimbursement of the same on 1.8.18.  In response, O.P No.1 issued a letter to O.P No.3 through registered post to enquire about the submission of final bill of hospitalisation.  On 25.8.18 the complainant No.2 had undergone further hospitalisation whose bill was attached to the tune of Rs.2630/-, hence the total claim was of Rs.61,246/-.  The final bill was received by O.P No.1 on 2.11.18 but since because no action was initiated, the complainant no.1 had issued reminder. As per the demand of O.Ps, the hospital authorities could not provide corporate final bill with a break up as they had no such facility in their hospital.  When no action was taken even after lapse of 30 days, both the complainants were constrained to issue legal notice to the O.Ps on 26.12.18 and an amended notice on 29.12.18.  In response to such legal notice, part payment was made by the O.Ps to the tune of Rs.28,600/- out of the total claim of Rs.61,246/- and the said part payment amount of Rs.28,600/- was credited to the bank account of complainants on 24.12.18.  Thereafter there was no response as regards to the balance amount of Rs.36,646/-.  Complainants thus allege that there was deficiency in service and unfair trade practice by the O.Ps.  Subsequently O.Ps were issued another legal notice dt.10.1.19 in response to which through their letter dt.15.1.19 they disclosed that the claim was settled for a sum of Rs.28,600/- but they  had not whispered anything about the balance amount.  Thus, the complainants have filed this case claiming the balance amount of hospitalisation to the tune of Rs.32,646/- together with interest @ 12% per annum with effect from 15.1.19 till the finalisation of payment alongwith litigation expenses  of Rs.30,000/- and cost of Rs.10,000/-.  They have also claimed compensation of Rs.50,000/- towards their mental agony and harassment from the O.Ps.

2.         Out of the 6(six)  O.Ps, arrayed in this case, O.P. No.5 & 6 have not contested this case for which they have been set exparte but the rest of the O.Ps No.1 to 4 have contested this case and have filed their written version conjointly.  As per the written version of the O.Ps 1 to 4, this complaint petition as filed is not maintainable, there was no deficiency in service, there was no unfair trade practice and thus there is no cause of action for which they have prayed to dismiss the complaint petition.  According to them, the complainants after receiving the settled amount are legally stopped to make further claim having executed the Health Insurance Policy discharge voucher with full and final settlement of the claim.  According to the O.Ps No.1 to 4, the settlement was done keeping in view the terms and conditions of the policy and the benefit enumerated in the policy for which there can be no further payment made to the complainants.  The O.Ps have further averred that the complainant was paid initial daily cash benefit of Rs.1000/- with an enhancing amount of 5% per annum since the policy was completed in two years.  According to them, the surgery undergone by complainant no.2 neither comes under major surgical benefit nor it comes under day care procedure benefit.  So as per the terms and conditions of the said Jeevan Arogya policy plan obtained by the complainants, they are entitled to get twice the amount applicable daily cash benefit multiplied with days of hospitalisation, i.e., Rs.1100 x 2 x 8 which is of Rs.17,600/-.  The two days ICU hospitalisation of complainant no.2 values for Rs.2x2x1100 which is equal to Rs.6600/-.  Hence the total and settled claim is Rs.6600/- + Rs.4400 + Rs.17,600/- which comes to Rs.28,600/-.  Thus the O.Ps 1 to 4 have claimed that they have settled the claim and that the complaint petition as filed has no merit and is liable to be rejected.

3.         Keeping in mind the averments as made out from the complaint petition and the written version as well, this Commission feels to caste the following issues for proper adjudication of this case.

            i.          Whether the case as filed is maintainable?

            ii.         Whether the complainants had any cause of action to file this case?

            iii.        Whether there was any deficiency in service on the part of O.Ps?

            iv.        Whether there was any unfair trade practice adopted by the O.Ps?

            v.         Whether the complainants are entitled to the reliefs as claimed by them?

Issue No.3.

            For the sake of convenience issue No.3 is taken up first for consideration here in this case.  The O.Ps have vehemently urged that there was no deficiency in service and that there was no such unfair trade practice as alleged.  Per contra, it is the consistent plea of the complainant that there was deficiency in service by the O.Ps.  While perusing case record and on going through the documents as available therein, it is noticed that no immediate steps was initiated by the O.Ps when the complainant initiated his claim against the policy taken for himself and his family members.  There was no promptitude shown as noticed from the side of the O.Ps in disbursing or settling the claim amount of the complainants.  As it appears, from the documents available therein, after getting repeated legal notices, the O.Ps were constrained to settle the claim in this case.  This attitude of the O.Ps imbibes this Commission to come to a conclusion that in fact there was deficiency in service on the part of the O.Ps.  Accordingly this issue is answered against the O.Ps of this case.

Issue No.4.

            As regards to unfair trade practice while analysing the documents as available in this case record it is noticed that the complainants had preferred the policy named and styled as “Jeevan Arogya Policy”.  They had paid the premiums as required and the policy was in existence.  The policy in between the complainants and the O.Ps is definitely a contract which had been acted upon by both the parties to this case.  There was definite initiation of proposal and acceptance by paying the premiums when the policy came into force.    As per the annexures filed regarding the said policy it could not be made out that if the calculation shown by the O.Ps that by way of which the claim amount of the complainants was settled was justified.  At the last page of their written version, it is found that they have relied upon certain annexures which they named as Annexure-A & Annexure-B but there is no such document available so as to apprise this Commission that the calculation as regards to the settlement of the claim is justified by the O.Ps.  Thus the O.Ps have not practised fair trade as it appears.  Accordingly this issue is also answered against the O.Ps.

Issue No.1 & 2.

            Now issues No.1 & 2 are taken up together for consideration.  When it is made out that there was in fact deficiency in service and unfair trade practice adopted by the O.Ps in delaying the settlement of the claim of the complainants, the complainants undoubtedly had cause of action to initiate this case and their case is definitely maintainable.  Accordingly these issues are answered in favour of the complainant.

Issue No.5.

            From the above discussions and conclusions, this Commission is of the opinion that the complainants are definitely entitled to the reliefs as sought for by them.  Hence it is so ordered;

                                                                ORDER

            The case is decreed on contest against the O.Ps No. 1 to 4 and exparte against O.Ps No.5 & 6.  O.Ps No.1 to 4 are found jointly and severally liable in this case.  The O.Ps No.1 to 4 are hereby directed to settle the claim of the complainants properly by paying the balance amount of hospitalisation fee to the tune of Rs.32,646/- together with interest @ 12% per annum with effect from 15.1.2019 till the payment is clear and also to pay a sum of Rs.10,000/- to the complainants towards the harassment caused to them and for the mental agony suffered by them.  The O.Ps are also directed to pay a sum of Rs.10,000/- towards cost of litigation to the complainants.  This order is to be carried out within a month hence.

Order pronounced in the open court on the 18^th day of May,2022 under the seal and signature of this Commission.

                                                                                                                                                                                                                                        

                                                                                                                             

                                                                                                                              Sri Debasish Nayak

                                                                                                                                        President

                                                                                                                       

                                                                                                                            

                                                                                                                         Sri Sibananda Mohanty

                                                                                                                            Member.