Orissa

Cuttak

CC/211/2022

Bharatendu Mohanty - Complainant(s)

Versus

Managing Director,Manipalcigna Health Insurance Company Ltd - Opp.Party(s)

B K Sinha & associates

22 Aug 2023

ORDER

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

C.C.No.211/2022

 

Bharatendu Mohanty,

S/o:Late Janmejaya Mohanty & Meera Mohanty

Of Chhakana,P.O:Indalo,Via:Danpur,

Disst:Kendrapada.

At present:Jhanjirimangala,Cuttack.                           ... Complainant.

 

          Vrs.

 

1.     The Managing Director,

Manipalcigna Health Insurance Company Ltd.,

At:401/402,Raheja Titanium,

Western Express Highway,

Goregaon East,

                      Mumbai-400063,India

 

2.     Manager, Manipalcigna Health Insurance Company Ltd.,

At:401/402,Raheja Titanium,

Western Express Highway,

Goregaon East,

                          Mumbai-400063,India

 

3.     Managing Director,

M/s. Bajaj Finance Limited,

                       2^nd floor,Sreema Construction,Below akash Institute

NH-16,Nayachowk,Madhupatna Colony,

Cuttack-753010.                                                     ...Opp.Parties

                      

 

 

Present:         Sri Debasish Nayak,President.

                      Sri Sibananda Mohanty,Member.

 

Date of filing:    12.10.2022

Date of Order:  22.08.2023

 

For the complainant:           Mr. B.K.Sinha,Adv. & Associates.

For the O.Ps no.1 & 2:                 Mr.D.Singh,Adv. & Associates.

For the O.P No.3:                          Mr. R.C.Panigrahi,Advocate.

 

                                      

 

Sri Debasish Nayak,President.

Case of the complainant as made out from the complaint petition in short is that his mother Meera Mohanty had obtained a Health Insurance Policy “Famili Floater” bearing policy no.100200085335/00/00 under Consumer I.D No.5903499 for a period of 1 year and had paid the premium of Rs.17,767/-.  As per the scheme of the said health insurance, she is entitled to get all the medical treatment expenses from the O.P company.  The father of the complainant was also enrolled in the said scheme being the husband of Meera Mohanty.  Unfortunately, the father of the complainant was diagnosed with Type-II M, HTN, CKD-5D, Pulmonary Oedema for which he was admitted at Kalinga Hospital on 11.10.2020.  He was treated with Haemodialysis costing of Rs.71,009/- but when the complainant had applied for cashless treatment, the O.Ps had not paid the same amount for which the complainant had to pay the entire hospital bill.   The complainant had filed thereafter a claim form towards medical treatment of his father, before the O.Ps.  His father again had fallen sick and was re-admitted to Kalinga Hospital on 3.11.2021 where the medical expenses were of Rs.62,467/-.  Again, the cashless provisions could not be obtained towards such treatment of the father of the complainant and rather the complainant was assured on each occasion that the money will be credited to his account after claim has been made in the claim form.  The father of the complainant was admitted to Kalinga Hospital for the third time for which the complainant had to incur expenses of Rs.59,577/- and though there was cashless provision from the O.Ps, it could not be availed.  Quite astonishingly, the claim of the complainant was repudiated by the O.Ps without notifying any specific reason thereof. The complainant when had failed to get reimbursed all the medical expenses from the O.Ps, inspite of his repeated efforts, he had issued notices to them on 10.5.2022 and 15.7.2022 and ultimately had also issued a legal notice to them on 28.7.2022.  Having no other way out, the complainant has filed this case seeking reimbursement of the medical expenses as incurred by him towards the medical treatment of his father at Kalinga Hospital on three occasions to the tune of Rs.71,009/- on 11.10.21, Rs.62,467/- on 3.11.2021 and Rs.59,577/-  alongwith compensation towards his mental agony and harassment and litigation cost to the tune of Rs.1,00,000/-.

          The complainant has filed copies of several documents alongwith his complaint petition in order to prove his case.

2.       On the other hand, out of the three O.Ps as arrayed in this case who have also  contested this case,  O.Ps no.1 & 2 have filed their joint written version whereas O.P no.3 has filed a separate written version of his own.  From the written version of the O.Ps no.1 & 2 it appears that the mother of the complainant had obtained health insurance “ManipalCigna Pro Health Group Insurance Policy” from them wherein the health issues of her husband Janmejay Mohanty was also covered.  But while obtaining the said policy, the policy-holder Meera Mohanty had not disclosed to be having coverage of Bajaj Finance Limited Senior Citizen Master Policy bearing no.100200084149-00-00.  The policy-holder had also suppressed the fact that Janmejay Mohanty was suffering from K/C/O Diabetes Mellitus for the last 17 years.  In this connection, the O.Ps have relied upon catena of decisions which they have cited in their written version which are as follows:

i.         In the case of Ravneet Singh Bagga Vs. KLM Royal Dutch Airlines reported in (2000) 1 SCC-66, the Hon’ble Supreme Court has observed that “The deficiency in service cannot be alleged without attributing fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance which is required to be performed by a person in pursuance of a contract or otherwise in relation to any service.  The burden of proving the deficiency in service is upon the person who alleges it”.

ii.       In the case of A Sanjeeva Narayan Vs. National Insurance Co. Ltd.  The National Consumer Disputes Redressal Commission in the instant case it was held therein that it is a well-settled law that the contract of insurance is the contract of Uberrimae Fide for both the parties which is in between the insured and the insurer.

iii.      In the case of Life Insurance Corporation of India & Ors. Vs. Smt. Asha Goel & Anr.; The Hon’ble Supreme Court relied upon Life Insurance Corporation of India Vs. Smt. G.M. Channabasamma (1991) (1) SCC 357, in which it was held that a contract of insurance is contract of Uberrimae fides and there must be complete good faith on the part of the assured.

iv.      In the case of New India Insurance Co. Ltd. Vs. M.K.J Corporation, it was held by the Hon’ble Supreme Court that it is a fundamental principle of Insurance Law that utmost good faith must be observed by the contracting parties.

v.       In the case of Satwant Kaur Sandhu Vs. New India Assurance Co. Ltd. [2009 (9) Scale 488] has held “a contract of insurance falling in the category of contract uberrimae fidei, meaning a contract of utmost good faith on the part of the assured.”

O.Ps no.1 & 2 have thus urged through their written version that the case of the complainant is not maintainable as it is contrary to the principles of Uberrima Fidei.  They also have stressed that the complainant is guilty of “suppressiovari and suggestiofalse”.  Thus, according to them, the complainant has not approached with clean hands and had rather suppressed the material facts.  These two O.Ps have prayed for dismissal of the complaint petition as filed by the complainant.

          In order to prove their stand, they have also annexed copies of several documents alongwith their written version.

          O.P no.3 has filed his written version wherein he has stated that the case of the complainant is not maintainable, the complainant has not approached with clean hands and had rather suppressed the material facts.  According to O.P no.3, the complainant being the son of the policy holder Meera Mohanty is not the customer and thus his complaint petition as filed before this Commissiion  is without jurisdiction.  According to O.P no.3, it is a dispute in between Meera Mohanty, the mother of the complainant and the O.Ps no.1 & 2 where the present complainant has no role to play.  According to O.P no.3, the complaint petition is liable to be dismissed.

          The O.Ps no.1 & 2 have filed their evidence affidavit also in this case through their authorised representative Swetha Nair but while perusing the contents of the evidence affidavit of the said Swetha Nair, it is noticed that the same appears to be a reiteration of the contents of the written version of O.Ps no.1 & 2 and nothing more.

3.       Keeping in mind the averments as made in the complaint petition and the contents of the written versions 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 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 is taken up  first for consideration here in this case.

             After going through the complaint petition, the two written versions, the written notes of submissions and all the copies of documents as filed from either sides, it is noticed that undoubtedly Meera Mohanty is the mother of the present complainant who had obtained Health insurance policy from the O.Ps no.1 & 2 which also covers the health issues of her husband Janmejay Mohanty.  It is not in dispute that Janmejay Mohanty, the father of the complainant was admitted to the Kalinga Hospital,Bhubaneswar on three occasions for his health issues and the complainant had to bear the medical expenses of Rs.71,009/- on the first occasion, a sum of Rs.62,467/- on the second occasion and a sum of Rs.59,577/- on the third occasion since because inspite of having cashless reimbursement provision for his father Janmejay Mohanty as per the policy of his mother Meera Mohanty, the O.Ps no.1 & 2 had not extended the benefits of the said policy in favour of Janmejay Mohanty.  The O.Ps no.1 & 2 had repudiated the claim of the complainant towards the medical expenses of his father Janmejay Mohanty on the said three occasions on two-fold grounds that prior to obtaining insurance policy from them, the policy-holder had another policy i.e. Bajaj Finance Limited Senior Citizen Master Policy which was not disclosed to them while obtaining the policy from them and secondly, because the father of the complainant was suffering from K/C/O Diabetes Mellitus for the last 17 years.  O.P no.3 has simply stated that this is a dispute between Meera Mohanty, the mother of the complainant and the O.Ps no.1 & 2 where the complainant has no role and his complaint as filed is out of the jurisdiction.  Quite surprisingly O.P no.3 has not stated that if at all either Meera Mohanty or Janmejay Mohanty had obtained any such Bajaj Finance Limited Senior Citizen Master Policy from his organisation where he is the Managing Director.  It is not understood as to why O.P no.3 did not disclose about the policy if any as alleged by O.Ps no.1 & 2; to have been obtained by either of the parents of the complainant from his organisation. Moreso, O.ps no.1 & 2 have further urged that Janmejay Mohanty was suffering from K/C/O Diabetes Mellitus since for the last 17 years which he had not disclosed to them while obtaining the policy through Meera Mohanty.  Keeping the same allegation in mind and while scanning all the medical documents as filed here in this case, it is noticed that while being admitted into the Kalinga hospital, Janmejay Mohanty was examined on 11.10.21 there at Kalinga Hospital where the doctor had opined that it was a known case of Type-II D.M for 17 years, HTN for one year etc.  As it appears that O.Ps no.1 & 2 had strongly relied upon such opinion of the Kalinga Hospital as reflected at Annexure-2 which is the examination report alongwith admission of the patient Janmejay Mohanty on 11.10.21 at Kalinga Hospital together with his Discharge certificate. When the O.Ps no.1 & 2 strongly urge that they had repudiated the claim of the complainant since because his father Janmejay Mohanty, who was under the health insurance coverage of the policy holder Meera Mohanty being her husband; was suffering from Type-II Diabetes Mellitus, they have not filed any scrap of document in order to apprise this Commission that infact the said patient Janmejay Mohanty was having Type-II Diabetes Mellitus past history of 17 years and was being treated for the same.  In absence of such pertinent document here in this case, the O.Ps have tried to wriggle out from the puddle of liability by taking lame excused and citing decisions to support them.  Thus, all the decisions as relied upon by O.Ps no.1 & 2 and has been cited here in this case are absolutely of no help to them.  They had drawn the attention of this Commission towards the principles of Uberrima Fidei, Suppressiovari and Suggestiofalsi.  But it is they who are to prove that if the complainant or his parents had suppressed anything knowingly and had not disclosed the said fact of previous illness of Janmejay Mohanty. Accordingly, the plea as erected by the O.Ps here in this case is noticed to be shingling down and by not entertaining the medical claims of the complainant of this case who is undoubtedly the beneficiary of the policy- holder Meera Mohanty his mother, by taking flimsy grounds without any authentication are also definitely found to be deficient in their service by not doing so.  The arbitrary and unilateral repudiation of the bonafide claim of the complainant by the O.Ps appears to be in-genuine and indicates the practice of unfair trade by them.  Hence this issue goes completely in favour of the complainant.

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 claimed by him.  Hence, it is so ordered;

                                              ORDER

Case is allowed 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 pay the complainant the total claim amount of Rs.1,93,053/- alongwith interest thereon @ 12% per annum from the date of 17.10.2021 till the total amount is quantified.  The O.Ps are further directed to pay the complainant a sum of Rs.50,000/- towards compensation for his mental agony and harassment and also to pay him a sum of Rs.50,000/-towards the cost of his litigation expenses.   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 22^nd day of August,2023 under the seal and signature of this Commission.         

                                                                                                                                                                                            

                                                                                  Sri Debasish Nayak

                                                                                            President

 

                                                                                             Sri Sibananda Mohanty

                                                                                                     Member