Orissa

Cuttak

CC/25/2023

Gopinath Padhi - Complainant(s)

Versus

Managing Director/Authorised Person,National Insurance Company Ltd - Opp.Party(s)

A K Mohanty & associates

07 Dec 2023

ORDER

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

C.C.No.25/2023

Gopinath Padhi,

S/o: Late Gopal Krishna Padhi,

Residing at Flat No.G-805,Block-G,

Dions River Front Apartment,

Plot No.414,Cuttack Extension,

             Near Trisulia,Naranpur,Cuttack-754005.                    ... Complainant.

 

          Vrs.

 

1.     National Insurance Company Ltd.,

Represented through its Managing Director/Authorised Person,

Having its head office at 3,Middleton Street,

Prafulla Chandra Sen Sarani,Kolkata,West Bengal-700071.

 

2.     National Insurance Company Ltd.,Cuttack,

Represented by its Senior Branch Manager,

With branch address as First Floor,AP Market Complex,

Allahabad Bank Premises,Link Road Square,

                    Madhupatana,Cuttack,Odisha-753010.                    ...Opp Parties                 

 

 

   Present:      Sri Debasish Nayak,President.

          Sri Sibananda Mohanty,Member.

 

  Date of filing:    24.01.2023

  Date of Order:  07.12.2023

 

  For the complainant:           Mr. A.K.Mohanty,Adv. & Associates.

     For the O.Ps 1 & 2   :            Mr. A.A.Khan,Adv & Associates.

 

     Sri Debasish Nayak,President

          Case of the complainant bereft unnecessary details as made out from the complaint petition in nutshell is that his wife had obtained a National Parivar Mediclaim Policy bearing No.163104501910000144 from the O.Ps which was effective from 4.3.2020 till 3.3.2021.  She had also paid the premium through which a floater sum of INR 2,00,000/- was insured under the said policy thereby covering health issues of the complainant/their younger son and herself.  Since because the complainant had sustained fracture by slipping down while walking on the road on 16.1.2021 at about 1.00 P.M, his Tibia Fibula was operated at Om Suvam Hospital of Cuttack.  The medical bill was raised in the said hospital to the tune of INR 1,99,184/- for the complainant and by way of cashless authorisation letter dated 21.1.2021, O.P no.3 through the policy as obtained by the wife of the complainant had only enabled a sum of Rs.1,00,000/- mentioning that the total expenses incurred for any one illness is limited to 50% of the sum insured.  According to the complainant, since because he had slipped down while walking and thereby had sustained fracture in his Tibia Fibula bone, it is an accident and never any illness.  When the O.Ps had not paid any further amount, the son of the complainant had to bear an amount of INR 69,267/- in order to clear the medical bill at Om Suvam Hospital on 22.1.2021 during discharge of the complainant.  The complainant thereafter had written and had sent mail dated 2.3.2021 to the Senior Branch Manager of the O.P Company claiming the balance INR of 69,267/- under policy no. 163104501910000144 but the O.Ps had remained silent without giving any positive response.  Ultimately having no other way out, the complainant had come up with this case before this Commission claiming the balance amount of INR 69,267/- from the O.Ps alongwith interest thereon @ 12% per annum.  He has also claimed INR 60,000/- from the O.Ps towards compensation for his mental agony and harassment and further an amount of Rs.10,000/- towards the cost of his litigation.  The complainant has further prayed for any other relief as deemed fit and proper.

          In order to prove his case, the complainant has filed copies of several documents alongwith his complaint petition.

2.       Out of the three O.Ps as arrayed in this case, having not preferred to contest this case, O.P no.3 has been set exparte vide order dt.17.4.2023.

 However, O.Ps no.1 & 2 have contested this case and have filed their joint written version.  The said contesting O.Ps through their written version have stated that the case of the complainant is not maintainable which is liable to be dismissed with cost as because the same is filed with an oblique motive only.  They admit to have issued the Parivar Mediclaim Policy bearing No. 163104501910000144 which was effective from 4.3.2020 till 3.3.2021 for the assured sum of Rs.2,00,000/-.  They had settled the Mediclaim of the complainant as per clause-3.15 of the terms and conditions of the said policy.  They have urged through their written version about the illness which according to them is to be covered for only 50% of the expenditure.  Thus, according to them they had rightly settled the Mediclaim of the complainant and the present complaint petition as filed is to be dismissed with cost.

In support of their stand they have filed evidence affidavit of one Sri Devi Prasad Dash,Senior Divisional Manager of their Company.  The contents of the said evidence affidavit when perused, it is noticed that the same is a precise form of the contents of the written version of the contesting O.Ps and nothing else.

3.       Keeping in mind the averments as made in the complaint petition and the contents of the written version of the O.Ps no.1 & 2, this Commission thinks it proper to settle the following issues in order to arrive at a proper 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 and if they have practised any unfair trade ?

  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 in this case, is taken up  first for consideration here.

              After perusing the complaint petition, the written version, written notes of submission as well as the documents as available in the case record together with the evidence affidavit from the side of the O.P, it is noticed that infact there was insurance coverage of the complainant and his family through policy No. 163104501910000144 issued by the O.Ps no.1 & 2 which was effective from 4.3.2020 till 3.3.2021 and the assured sum therein was of Rs.2,00,000/-.  It is also not in dispute that on 16.1.2021 the complainant had sustained fracture of his Tibia Fibula bone as he had slipped during walking on the road and was operated at Om Suvam Hospital of Cuttack.  The medical bill raised at Om Suvan Hospital towards the treatment of the complainant was of INR 1,99,184/- which is also not in dispute.  The O.Ps had paid a sum of INR 1,00,000/- only without paying the total medical bill as raised at Om Suvan Hospital towards the treatment of the complainant.  It is the contention of the O.Ps that as per the definition of illness  50% of the medical expenses is to be borne and paid only.  But while perusing the terms and conditions of the Parivar Mediclaim Policy for family of the O.P Company as per Annexure-2, which is a copy thereof it is noticed that under clause-3.1 definition accident has been defined which means a sudden unforeseen and unvoluntary event caused by external, visible and violent means.  Thus, accident and illness vary widely and are not the same thing at all.  Here as it is noticed that the complainant was not suffering from any illness, rather he had met with an accident as he had fallen down by slipping suddenly while walking on the road on 16.1.2022 at about 1.00 P.M.  Thus, it is noticed from the facts and circumstances of this case is that, the O.Ps by not reimbursing the total Mediclaim amount within the assured sum when such Mediclaim was raised by the complainant who was under the coverage of the insurance policy, the O.Ps are noticed to be wilfully deficient in their service and thereby  have practised unfair trade also.  Accordingly, this issue 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 the complainant is entitled to the reliefs as claimed by him. Hence, it is so ordered;

                                                          ORDER

                The case is allowed on contest against the O.Ps 1 & 2 and exparte against O.P no.3 who are all found to be jointly and severally liable here in this case. The O.Ps are thus directed to pay the complainant the balance medical bill amount INR 69,267/- i.e, Rs.69,267/- alongwith interest thereon @ 12% per from the date of his application till the total amount is quantified.  The O.Ps are also directed to pay a sum of  INR 60,000/- i.e. Rs.60,000/- to the complainant towards his mental agony and harassment as well as a sum of INR 10,000/- i.e. Rs.10,000/- towards 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 the 7^th day of December,2023 under the seal and signature of this Commission.  

 

                                                                                              Sri Debasish Nayak

                                                                                                        President

 

 

                                                                                 Sri Sibananda Mohanty

                                                                                                              Member