Orissa

Cuttak

CC/13/2014

Sumitra Prusty - Complainant(s)

Versus

Managing Director,HDFC ERGO General Insurance Company Limitad - Opp.Party(s)

A K Samal

17 Dec 2022

ORDER

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

C.C.No.13/2014

 

Sumitra Prusty,

W/O:LatePaprthaSarathiPrusty,

Res. Of At:Nuapatna,PO:BuxiBazar,P.S:Mangalabag,

Town/Dist:uttack,Pin-753001                .                                ... Complainant.

 

                                                             Vrs.

1.        HDFC ERGO General Insurance Company Ltd.,

Corporate Office: 6^th Floor, Leela Business Park,Andheri-Kurla Road,

             Andheri East(Mumbai)

(Maharastra) represented by its Managing Director.

 

2.         HDFC Bank Ltd.,JholaSahi Branch,

At:JholaSahi,PO:Buxi Bazar,

Town/Dist:Cuttack,Pin-754021,

represented by its Br. Manager.                                                       ... Opp. Parties.

 

 

Present:    Sri Debasish Nayak,President.

                    Sri SibanandaMohanty,Member.

 

   Date of filing:     29.01.2014

Date of Order:    17.12.2022

 

For the complainant:           Mr. A.K.Samal,Advocate.

For the O.P.No.1  :Mr. R.Pati,Adv. & Associates.

For the O.P No.2       :           Mr. N.K.Dash,Adv& Associates.

 

Sri Debasish Nayak,President                                    

          The case of the complainant as made out from the complaint petition bereft unnecessary details in short is that O.P no.2 had obtained a policy named and styled as “SarvSurakhya Star” in favour of the husband of the complainant through HDFC ERGO General Insurance Company Ltd.(O.P no.1) vide policy no.2950200336135400000.  By virtue of the said policy there was coverage on various matters which is defines below:

Coverage                                                      Premium         Sum Insured

Credit Shield Insurance                                Rs.   86.00       Rs.  1,00,000/-

Householders Coverage                               Rs. 284.00       Rs.   1,50,000/-

Accidental Hospitalization                            Rs.     86.00    Rs.     50,000/-

 

Permanent Total Disability/

Permanent Partial Disability                            Rs.   138.00             Rs.  2,00,000/-

 

Loss of Job(3 EMI)                                         Rs.      56.00    Rs.       25,000/-

Accidental Death                                          Rs.     104.00   Rs.    2,00,000/-

Critical Illness                                               Rs.      605/-     Rs.     1,00,000/-

 

The O.P no.2 was paid the insurance premium of Rs.605/-.  On 18.6.13 while the said policy was inforce, the husband of the complainant fell ill for which he was examined by Dr.Budhadeb Dey who opined that the husband of the complainant had sustained cardiological ailments and had prescribed medicines accordingly to him.  Again on 24.7.13, the husband of the complainant suffered massive chest pain and shock even though he has been treated by Professor Dr.D.N.Moharana,HOD Geriatrics Ward of SCB Medical College and Hospital, Cuttack.  The husband of the complainant succumbed to his ailments few minutes thereafter on 24.7.13.  The death of the husband of the complainant was informed to O.Ps by the brother of the deceased and the required documents were also provided to them.  But the complainant received a letter from O.P no.1 that under critical illness to be admissible under the policy obtained, the insured has to survive for a minimum period of 30 days from the time he was diagnosed of critical illness and since because that condition was not fulfilled, the claim as made for the deceased insured was repudiated.  The treating Physician Professor Dr.D.N.Moharana had mentioned in his report about the deceased patient, the husband of the complainant was not having any prior history of illness but had sudden  massive chest pain and shock.  The complainant through her complaint petition has urged that she is entitled to get insurance claim towards the treatment of her deceased husband from the O.Ps to the tune of Rs.1,00,000/- together with another sum of Rs.1,00,000/- from them towards her mental agony and harassment and she is also entitled to get interest from the O.Ps over her claim amount.  She has prayed for the cost from the O.Ps together with any other reliefs as deemed fit and proper. 

The complainant has filed copies of several documents inorder to establishher case.  Besides that she has also filed her evidence on affidavit which when perused appears to be the reiteration of the complaint petition.

2.       Both the O.Ps have contested this case but they have filed their respective separate written versions in this case.  As per the written version of O.P no.1, the case of the complainant is not maintainable which is liable to be dismissed.  Ofcourse they admit about the “SarvSurakhya Star” policy to have been obtained by the deceased Partha Sarathy Prusty, who is the husband of the complainant of this case; for a sum of Rs.1,00,000/- towards critical illness which was valid from 24.9.12 to 23.9.14.  It is alleged by the O.P no.1 through his written version that after getting intimation about the treatment of the deceased Partha Sarathy Prusty they had written several letters and also sent several reminders to the deceased insured in order to provide the treatment certificate, medical documents etc.  O.P no.1 admits about the death of Partha Sarathy Prusty on 24.7.2013 due to massive chest pain few minutes he was being treated by Professor Dr.D.N.Moharana, HOD Geriatrics Ward of SCB Medical College and Hospital at Cuttack.  In this context, the O.P no.1 through his written version has urged that the insured if diagnosed critical illness during the subsistence of the policy, he would onlybe entitled to claim as per terms and conditions of the said policy; after surviving for a minimum period of 30 days from the date of such diagnosis.  According to O.P no.1, the deceased Partha Sarathy Prusty had died few minutes after being diagnosed about the critical illness on 24.7.13 which is not inconformity to the terms and conditions of the policy as availed by him.So the claim as made on behalf of him towards his treatment was rightly repudiated and thus it is prayed by O.P no.1 to dismiss the complaint petition with exemplary cost it being not maintainable.

          O.P no.1 has filed copies of the policy as availed by the deceased Partha Sarathy Prusty alongwith the details of the terms and conditions as envisaged therein in order to prove his stand.  O.P no.1 has also filed her evidence on affidavit in this casewhich when perused appears to be the reiteration of her written version.

          As per the written version of O.P no.2 bereft unnecessary details in short is that the case of the complainant is not maintainable.

3.   Keeping in mind the averments as made in the complaint petition and the contents of both the written versions of O.Ps, this Commission thinks it proper to settle the following issues in order to arrive at a proper conclusion.

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 had practised any unfair trade ?

iii.        Whether the complainant is entitled to the reliefs as claimed by him?

Issues no.II.

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

Admittedly, the deceased husband of the complainant late Partha Sarathy Prusty had a “SarvSurakhya Star” policy for which he had paid premium of Rs.605/- towards coverage of critical illness which was effective when he died.  The wife of the deceased Partha Sarathy Prusty who is the complainant of this case, when advanced claim of the said policy towards the death of her husband, the same was repudiated since because the deceased had died minutes after being diagnosed of having massive chest pain and shock on 24.7.13 by the treating physician Professor Dr.D.N.Moharana, HOD Geriatrics and Superintendent, Medical College and Hospital at Cuttack.  Since because the deceased had not survived for a minimum period of 30 days after being diagnosed of his critical illness, the claim was repudiated by the O.Ps.  Quitie interestingly, the O.Ps did not dispute about the earlier treatment of the said deceased on 18.6.13 by treating Dr.Budhadevb Dey who had opined that the said deceased Partha Sarathy Prusty was having cardiological ailments after examining him thoroughly.  Thus, it is well within the knowledge of the O.Ps that since 18.6.13 the deceased Partha Sarathy Prusty had fallen ill and was having cardiological ailments for which he was prescribed medicines by the then treating physician Dr.Budhadeb Dey and the same was within the knowledge of atleast O.P no.1 who has admitted the same in his written version.  In this context O.P no.1 has submitted through his written version that after getting such information about the treatment of Partha Sarathy Prusty by Dr.Budhadeb Dey they had issued several letters/reminders to the complainant asking her to produce the treatment papers of Partha Sarathy Prusty.  Thus, it cannot be said here in this case that the complainant had not survived for a minimum period of 30 days after being diagnosed to be having cardiological ailments/critical illness since because the O.P no.1 knew that Dr.Budhadeb Dey had already diagnosed about the critical illness of the patient Partha Sarathy Prusty since 18.6.13.  Thus by repudiating the claim, the O.Ps are definitely deficient in their service and are also found to have practised unfair trade here in this case.  Accordingly, this issue goes against the O.Ps of this case.

Issues no.i& iii.

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

                                    ORDER

Case of the complainant is decreed on contest 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 by paying a sum of Rs.1,00,000/-  alongwith interest @ 12% per annum from the date of claim i.e. from 10.12.2013 till the payment is fully made.  The O.Ps are further directed to pay a sum of Rs.1,00,000/- to the complainant towards compensation towards her mental agony and harassment as well as a sum of Rs.30,000/- towards her litigation expenses.  This order is to be carried out within a period of 30 days from the date of receipt of this order.

Order pronounced in the open court on the 17^th day of   December,2022 under the seal and signature of this Commission.       

                                                                                                                          Sri Debasish Nayak

                                                                                                                                    President

                       

                                                                                                                Sri Sibananda Mohanty

                                                                                                                         Member