Orissa

Cuttak

CC/60/2023

Rasmita Mishra - Complainant(s)

Versus

Managing Director,Bharati Axa Life Insurance Co Ltd - Opp.Party(s)

S K Singh & associates

06 Oct 2023

ORDER

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

                                                             C.C.No.60/2023

Rasmita Mishra,

W/o: Late Abdul Bari,

At:MB/2,Housing Board Colony,

P.O:Barmunda,Bhubaneswar,Dist:Khurda,

Presently residing At:Mukram Manzil,

C/o: Syed Obeidullah,P.O:Odia Baxar,

Dist:Cuttack,Odisha.                                                         ... Complainant.

 

                           Vrs.

1.          Bharti AXA Life Insurance Co. Ltd.,

      Represented by its Chief Executive Officer/Managing Director,

      Regd. H.O:At:Unit No.1904,

      19^th Floor,Parinee Crescenzo, ‘G’ Block,

      Bandra Kurla Complex,BKC Road,

      Behind MCA Ground,Bandra East,

      Mumbai,State:Maharastra-400051.    

 

2.         The Head of Claims Department

     Bharti AXA Life Insurance Co. Ltd.,

     At: Spectrum Tower,3^rd Floor,

     Opp. Ever Shine Mall,Malad Link Road,  

     Malad(West),Mumbai, State:Maharastra-400064.

 

3.         The Assistant Manager,

      Customer Care,Bharti AXA Life Insurance Co. Ltd.,

      At: Spectrum Tower,3^rd Floor,

      Malad Link Road,  

      Malad(West),Mumbai, State:Maharastra-400064.

 

4.         The Branch Manager,

     Bharti AXA Life Insurance Co. Ltd.,

     Bhubaneswar Branch,At:760,2^nd Floor,

     M.J.Plaza,Cuttack Puri Road,

     P.O:Bhubaneswsar,Dist:Khurda,Odisha-751009.              … Opp. Parties.

 

 

   Present:   Sri Debasish Nayak,President.

                    Sri Sibananda Mohanty,Member.

 

Date of filing:      24.02.2023

Date of Order:    06.10.2023

For the complainant:          Mr. S.K.Singh,Adv. & Associates.

For the O.Ps                :          Mr. D.Pattnayak,Advocate.

 

Sri Sibananda Mohanty,Member.

          The case of the complainant in short is that her husband Late Abdul Bari had taken a health insurance policy i.e. Bharati AXA Life triple insurance policy bearing No.501-4858780 from the O.Ps on 26.9.2016 to the tune of Rs.4,00,000/-. The complainant was nominee in the said policy.  She also had a similar identical policy in her name as issued by the O.Ps bearing policy No.50-4858780.  It is stated by the complainant that her husband was tested Covid positive on 3.5.2021 and thereafter he was admitted to Care Hospital at Bhubaneswar on 12.5.2021 complaining of shortness of breath, and cough for four days.  The husband of the complainant died on 21.6.2021 in the course of treatment at the said hospital and the cause of death was Septic shock with MODS post-Covid-19 Pneumonia Type-2 respiratory failure, hypoxic encephalopathy.  It is stated by the complainant that in order to avail benefit of expenses incurred towards the treatment of her husband under the policy, she contacted one Mr. Malay Mohapatra of Bharti AXA Life Insurance Company Ltd,Bhubaneswar branch and as per his advice she submitted the original policy bond of her late husband alongwith all original medical bills and documents.  It is further stated by the complainant that inspite of her repeated correspondences, the O.Ps did not settle her claim amount. Finally on 9.9.2021 the O.Ps repudiated the claim of the complainant on the ground that the deceased husband of the complainant had a policy which is without return of premium variant and no death benefit is payable on it.   It is stated by the complainant that after receiving such repudiation letter from the O.Ps, she represented to the O.Ps by way of letters and explained that she has not claimed death claim benefit rather she had claimed medical expenses which were incurred during the treatment of her husband.  But the O.Ps remained adamant in settling her claim.  Hence, the complainant has filed the present case with a prayer for a direction to O.Ps to settle the insurance claim to the tune of Rs.4,00,000/- alongwith interest thereon besides payment of Rs.2,50,000/- towards the compensation for his mental agony and cost of litigation.

          In order to prove her case, the complainant has filed certain documents alongwith her complaint petition.

The complainant has filed evidence on affidavit which when perused it is noticed that the same is only reiteration of the complaint petition and nothing else.

2.       Both the O.Ps have not filed written version and they were set exparte but participated in hearing of the case and they have filed their written notes of submission.

3.       The points for determination in this case are as follows:

                       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 her?

Point No.ii.

Out of the three points, point no.ii being the most pertinent point is taken up first for consideration here in this case.

The O.Ps in their written notes of submission admitted the policy.  Learned counsel for the O.Ps argued that as per the policy conditions, the complainant is not entitled to get any benefit as the life assured had opted the policy where the medical expenses cannot be reimbursed for the illness suffered by the policy holder as per the policy condition so also the policy being a without return premium variant option nothing can be settled in favour of the complainant.  The O.Ps also argued and stated that policy holder concealed the fact that he was suffering from the diabetes as such the contract between the parties being a void one, the complainant is not entitled to get any benefit.  The O.Ps also have taken another stand and argued that as the policy holder is already dead, the complainant is not entitled to get any benefit.  Only this stand of O.Ps corroborates with the repudiation letter.   

The complainant vide Annexure-5 has filed repudiation letter of O.Ps wherein it is stated that the policy in question is a “without return of premium variant and no death benefit is payable on it”.  The O.Ps have not filed their written version.  But in the written notes of submission filed by the O.Ps reveals different grounds of repudiation of claim of the complainant besides the grounds taken in the repudiation letter.  Such attitude of O.Ps speak their malafide intention.  It is argued on behalf of the O.Ps that the policy holder had concealed the fact that he was suffering from the diabetes.  It is well settled law that the diabetes is not a disease.  So also the cause of death of policy holder has no nexus with the diabetes.  As such the O.Ps cannot repudiate the claim of the complainant on this ground.  Be that as it may, the complainant has claimed medical expenses incurred during the treatment of her husband, the policy holder.  The complainant has neither claimed refund of premium, nor the death benefit claim of her husband.  The husband of the complainant died during course of treatment.  Both the parties have filed policy conditions.  In the said policy condition, there is no such clause to the effect that in case of the death of policy holder, his nominee would not be entitled to get the medical expenses incurred during the treatment of said policy holder.  So also in the exclusion clause, there is no such provision that the nominee of the policy holder is not entitled to get any benefit if during course of treatment, the policy holder dies and such plea of the O.Ps is unwarranted and not tenable in the eye of law.

Thus, it is concluded that the complainant is entitled to get her claim amount.  The O.Ps by not disbursing the claim amount of the complainant have committed deficiency of service as well as have adopted unfair trade practice. 

Points no.i & iii.

          From the discussions as made above, the case of the complainant is definitely maintainable and the complainant is entitled to get the reliefs as claimed by her.  Hence, it is ordered;

                                                          ORDER

          The case is allowed exparte against the O.Ps who are found to be jointly and severally liable here in this case.  Thus, the O.Ps are directed to settle the claim of the complainant and pay her Rs.4,00,000/-  towards the medical expenses incurred by her during treatment of her husband/policy holder.  The O.Ps are also directed to pay a sum of Rs.1,00,000/- to the complainant towards compensation for her mental agony and harassment so also a sum of Rs.20,000/- towards cost of her 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 6^th day of October,2023 under the seal and signature of this Commission.                                                                                                                               

Sri Sibananda Mohanty

                                                                                                          Member.

 

 

                                                                                      Sri Debasish Nayak

                                                                                              President.