Orissa

Cuttak

CC/136/2023

Bimal Kumar Modi - Complainant(s)

Versus

Manager,Star Health & Allied Insurance Co Ltd - Opp.Party(s)

R Pati & associates

20 Jul 2024

ORDER

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

C.C.No.136/2023

Bimal Kumar Modi,

S/o: Lat Babulal Modi,

At:Near Municipal Corporation Petrol Pump,

Choudhury Bazar,P.O:Telenga Bazar,

                    PS:Purighat-753009.                                                     ...Complainant

 

          Vrs.

 

1.        The Manager,

Star Health And Allied Insurance Company Ltd.,

Plot No.1677(P) 1678, Holding No.608,

Second Floor,Gajanan Complex,Dolamundai,

                P.O Buxibazar,Cuttack-753001.

 

2.       Medical Superintendent,

Shanti Memorial Hospital Pvt. Ltd.,

Pattnaik Colony,Thoria Sahi,

Near Mangalabag,Hanuman Mandir,

                 Cuttack-753001                                                                              ...Opp.Parties

 

Present:         Sri Debasish Nayak,President.

                      Sri Sibananda Mohanty,Member.

 

Date of filing:    01.05.2023

Date of Order:  20.07.2024

 

For the complainant:            Mr. R.Pati,Adv. & Associates.

For the O.P no.1       :            Mr. R.C.Sahoo,Adv. & Associates.

For the O.P No.2       :                     None.  

 

Sri Debasish Nayak,President

Case of the complainant as made out from the complaint petition in short is that the complainant Bimal Kumar Modi had procured health insurance for himself and his family consisting of his wife, son and daughter from O.P no.1 vide policy number P/1912012016/003616.   The assured amount was of Rs.3,00,000/- for each of the insureds and it was effective from 15.2.2016 to 14.2.2017.  The said policy was being renewed from time to time which was thus effective from 15.2.2020 to 14.2.2021.  On 12.2.2021, the complainant while cycling at about 6.00 p.m, had fallen down on the road due to imbalance and had thereby sustained severe injuries at  his face and teeth.  Intimation to that effect was given to the O.P no.1 on 13.2.2021 through e.mail.  The complainant was shifted to Bajaj Denal Care & Research Institute as there was zygoma including fracture of two of his teeth.  The complainant had claimed a sum of Rs.5,788/- towards treatment from O.P no.1.  On 21.2.2021 such claim of the complainant was received by the said O.P no.1 who besides asking for certain documents had wanted the FIR copy but since because the police had refused to accept the FIR of the complainant or to make any station diary, there was no such document available in that context. All the other papers including the treatment papers were submitted to the O.P no.1 in order to process the claim.  The O.P no.1 had released part payment of Rs.863/- but had refused to pay the balance amount of Rs.4,925/- on certain flimsy grounds.  The O.P no.1 through letter dated 1.8.2021 had refused to pay anything more to the complainant specifying therein that the implant surgery is excluded from the policy conditions.  Being dissatisfied, the complainant had moved the matter before the Insurance Ombudsman on 2.8.2021 and the learned Ombudsman vide order dated 29.11.2021 though held that there was clear deficiency of service and harassment on the part of the Insurance Company but had opined that treatment as regards to implant surgery was excluded from the policy condition for which it could not be paid to the complainant.  When the complainant consulted his Dentist, Dr. Bajoria seeking alternative way of treatment other than implant surgery, he was suggested for crown and bridge method of treatment.  But such subsequent claim of the complainant was also denied by the O.P no.1 through their letter dated 18.1.2022.  The complainant had put forth his grievances before the PLA(PSU) but there was no result had yielded.  Thus, on 10.3.2023, the complainant went for treatment with O.P no.2 and on 11.3.2023 the complainant had claimed for cashless treatment of Rs.1,30,000/- as estimated there but the same was denied by the O.P no.1 which was communicated through their letter dated 12.3.2023.  Thus, having no other way out, the complainant has approached before this Commission with his petition seeking compensation to the tune of Rs.2,00,000/- from O.P no.1 alongwith a sum of Rs.1,00,000/- towards compensation for his mental agony and harassment alongwith cost of his treatment at Shanti Hospital.  He has also prayed for any other order as deemed fit and proper.

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

2.       Out of the two O.Ps, O.P no.2  has been set exparte vide order dated 23.6.2023.  However, O.P no.1 has contested this case and has filed his written version wherein he has admitted that the complainant had obtained from him one Health Optima Insurance Plan vide policy number P/191212/01/2016/003616 covering the health risks of himself, his wife, his daughter and his son which was initially effective from 15.2.2016 to 14.2.2017 which  was being renewed from time to time and was effective on 12.2.2021 when the complainant had met with a cycle accident resulting loss of two number of teeth for which he  was under the treatment of Dr. Bajoria, Dental Care & Research Institute at Cuttack wherein he had incurred an expenditure of Rs.5,800/- and he had putforth  his insurance claim for the said amount.  But after considering the materials available, O.P no.1 had settled the claim to the tune of Rs.863/- only which was paid to the complainant.  Subsequently on 20.4.2021, the complainant had raised his claim for a sum of Rs.52,000/- but since because the implant surgery of teeth was not covered under the policy and the treatments undergone by the complainant were not according to the terms and conditions of the policy, the claim of the complainant was repudiated on 1.8.2021.  The further claim of the complainant was of Rs.75,000/-.  The learned Ombudsman while passing his award dated 15.11.2021 had directed O.P no.1 to pay Rs.5,325/- only.  The complainant being aggrieved with the award of the learned Ombudsman had preferred to approach the PLA(PUS),?Cuttack vide Case No.27 of 2022 seeking direction to O.P no.1 therein to settle the claim for Rs.52,000/-.  But, while the said case was sub-judice on 2.3.2023, the complainant had withdrawn the said case which was pending before the PLA(PUS) by filing a withdrawal memo there.  On 11.3.2023, he got himself admitted to Shanti Hospital (O.P No.2) and had again requested for cashless treatment.  O.P no.1 after enquiry had requested the Hospital authorities (O.P no.2) to submit the letter of the treating doctor of the complainant with exact diagnosis and complete PREAUTH form and the planned treatment of action.  On 12.3.2023 the requested for cashless treatment of the complainant was turned down as it was not admissible under the provisions of Exclusion Clause no.32 of the policy which was obtained by the complainant.  O.P no.1 has further urged that the complainant without undergoing any treatment and without seeking reimbursement of the alleged expenses towards his treatment has straight away approached this Commission seeking compensation on the ground of delay in settlement of his claim and has also sought for compensation towards harassment alongwith his treatment cost.  It is further urged by the O.P no.1 that since when the complainant has not undergone any treatment and had not lodged any claim before him seeking reimbursement of the alleged expenses as incurred towards his treatment, O.P no.1 has no scope to deal with the same and hence there was no cause of action for filing this case which according to O.P no.1 deserves to be dismissed with cost.

          Together with the written version, the O.P no.1 has also filed a copy of the order as passed by the learned PLA(PUS), Cuttack.

          The complainant has filed his evidence affidavit here in this case which when perused appears to be a reiteration of the averments as made in the complainant petition.

          Similarly, O.P no.1 has filed evidence affidavit through one Purnendu Kumar Rath, working as Zonal Manager for the O.P company but the contents of the said evidence affidavit of said Purnendu Kumar Rath, when perused it also appears to be the reiteration of the contents of the written version of O.P no.1.

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

 

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.

After perusing the complaint petition, written version, written notes of submission 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 in fact Bimal Kumar Modi, the complainant had procured a Health Insurance Plan for himself as well as for his inmates wherein the assured value for each of the inmates of his family including himself was of Rs.3,00,000/- and the said policy being renewed was effective from 15.2.2020 to 14.2.2021.  It is not in dispute that on 12.2.2021 at 6.00 P.M due to cycle accident the complainant had sustained injury at his face and teeth.  Initially, the complainant had raised his claim towards his treatment before the O.P no.1 for a sum of Rs.5,788/- but the said claim of the complainant was reduced by O.P no.1 through his letter dated 1.8.2021 who had released a sum of Rs.863/- only from the said claim amount which according to O.P no.1 is the only amount that which the complainant is entitled towards his treatment.  It is also not in dispute that being aggrieved, the complainant had approached the learned Insurance Ombudsman who by virtue of it’s award had directed the Insurance Company to pay a sum of Rs.5325/- on 15.11.2021.  Taking into account the facts and circumstances of the case and the submissions made by both the parties during the course of hearing, it is noticed that the implant surgery of tooth is excluded under the policy and therefore the complainant is not entitled for his estimated amount of Rs.75,000/-.  But it is noticed that the insurer knowing pretty well about the exclusion, was asking for various queries from time to time to the insured complainant which is nothing but harassment which is not at all proper on the part of the insurer.  The complainant is entitled for his claim for Rs.5788/- plus Rs.400/- towards test and therefore, the insurer is liable to pay the complainant Rs.6188/-.  Since the insurer has already paid Rs.863/-, the insurer is directed to pay the complainant the balance amount of Rs.5,325/- towards full and final settlement of the claim. Subsequently again being aggrieved, the complainant had moved his petition before the learned PLA(PUS) but subsequently the same was withdrawn by the complainant by filing a withdrawal memo. 

The complainant has come up with his case before this Commission alleging that the O.P no.1 had repudiated all his claims without any valid reason and had only made a part payment of Rs.863/- though he had claimed for a sum of Rs.5788/- initially.  It is prayed by the complainant that though he had opted for money for implant surgery, the O.P no.1 denied his claim intimating him that the same is not admissible.  Subsequently, the complainant had again met his Dental doctor Dr. Bajoria who had suggested him for crown and bridge method of treatment and the same was also denied by O.P no.1.  Lastly, the complainant had gone to O.P no.2 and had raised a claim of Rs.1,30,000/- before O.P no.1 on 11.3.2021 but the same was also repudiated by O.P no.1 through their letter dated 12.3.2023.  In this context, O.P no.1 through his written version has stated that the prayer for cashless treatment as made by the complainant when considered it was noticed by O.P no.1 that as per the policy plan, the complainant was not entitled for any cashless treatment vide Exclusion clause no.32 of his policy.

  It is further urged by O.P no.1 that since because the complainant had not undergone any other treatment subsequently and has not submitted his treatment bills alongwith his such claim, he is not entitled for any claim as made by him which were based upon estimations only for which all his claims were being rejected.  Infact after perusing the documents available in this case record, it is noticed that the complainant had incurred a sum of Rs.5788/- only while being treated for his teeth.  Out of the said amount when claimed, a sum of Rs.863/- was reimbursed by O.P no.1 but the balance amounts were denied.  Being aggrieved, the complainant had preferred to file a petition before the learned Insurance Ombudsman who vide his award dated 15.11.2021 had directed the Insurance Company to pay the balance of the said amount to the complainant towards full and final settlement of the claim.  Ultimately the O.P no.1 had not opted to go for any appeal or revision nor has challenged such award of the learned Insurance Ombudsman.  There is no such document put forth before this Commission to apprise this Commission that infact the award of the learned insurance Ombudsman was carried out.  Admittedly when the complainant had not undergone any subsequent treatment, his subsequent claims basing upon the estimation of treatment cannot be said to be justified and denial to such subsequent claims do not indicate any deficiency on the part of O.P no.1 but since because the O.P no.1 had not carried out the awarded money of the learned Ombudsman and had not paid the balance amount of Rs.5325/- to the complainant to which he is entitled, such demeanour of the O.P no.1 clearly indicates deficiency in service on his part for which this Commission comes to a conclusion that this issue goes in favour of the complainant.

 

Issues no.i & iii.

From the discussions as made above, the case of the complainant is maintainable and he is entitled to the reliefs as claimed by him from the O.P no.1 to some extent.  Hence it is so ordered;

ORDER

The case is decreed on contest against the O.P no.1 and exparte against O.P no.2.   The O.P no.1 is thus directed to pay the balance claim amount of Rs. 5,325/- to the complainant with immediate effect.  The said O.P is also directed to pay the complainant an amount of Rs.30,000/- towards compensation for his mental agony and harassment as well as a further sum of Rs.20,000/- towards the cost of his litigation.  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 20^th day of May,2024 under the seal and signature of this Commission.         

                                                                                      

                                                                                      Sri Debasish Nayak

                                                                                              President

 

 

                                                                                          Sri Sibananda Mohanty

                                                                                                      Member