Orissa

Rayagada

CC/118/2014

Sri Y. Mallikarjuna Rao - Complainant(s)

Versus

M/s Universal sompo General Insurance company Ltd., - Opp.Party(s)

21 May 2015

ORDER

DISTRICT   CONSUMER  DISPUTES REDRESSAL    FORUM, RAYAGADA

AT:  KASTURI  NAGAR, Ist.  LANE,   L.I.C.OFFICE BACK PO/DIST: RAYAGADA ,

                                                                 STATE:ODISHA,  PIN  NO.765001,  PHONE/FAX                  

 NO.06856-223025.

                                     ....                                  

                                              C.C. Case  No.118/ 2014.

 P R E S E N T .

Sri Pradeep Kumar Dash, LL.B,                              President.

Smt. Ch.  Nirmala Kumari Raju, LLB,                     Member.

            Sri  Y.Malikarjuna Rao, Prop. Utkal Printers, Station Road, Rayagada, Po/Ps/ Dist. Rayagada,                                                                         ….…….Complainant

                                                            Vrs.

1. M/s  Universal Sampo General Insurance Company Ltd.,Regd. Office Unit No.401,4^th Floor, Sangam Complex,127 ,Andheri Kurla Road, Andheri East,Mumbai-400059.
2. Branch Manager, IOB, Rayagada, IOB Health Care Plus Policy.

                                                                                                                …….…..Opp.Party

Counsel for the parties:

For the complainant: In Person

For the O.P No.1: Exparte     

For the O.p No.2: Sri K.Ch.G.S.Kumudan, Advoate, Rayagada.

                                                                     JUDGMENT

The facts of the complaint  in brief is that   the complainant   is  a customer of the O.p 2 and the said bank has introduced a scheme known as IOB Health Care Plus policy to its account holder and the complainant has availed the said opportunity and regularly he is subscribing for the same through deductions from him bank account. The O.p 2  has given the policy bond for the  year  w.e.f 30.03.2013 to 29.03.2014 vide Policy No.2817/50556264/03/00  and the said policy was renewed from year to year. The complainant has paid a premium of Rs.2651/- for health insurance, Rs.46/- for personal accident coverage and other charges  and in total Rs.3030/-. As per the said policy the complainant is entitled to get reimbursement of the treatment incurred by him for his family members whose names have been mention in  the  said policy bond. The wife of the complainant was admitted into Care Hospital for her  sufferings and incurred a sum of Rs.15,545/-  and the payment bill was also obtained from the said hospital  and the said treatment is within the policy period. When the complainant submitted the bills for its reimbursement  they have refuted the claim with false and pre determined plea  to avoid the said payment. Hence, prayed  to direct the O.ps  to pay the  amount  and award compensation for the mental agony and financial loss and cost of litigation and such other relief as the forum deem fit and proper. Hence, this complaint.

 

Being noticed, the Opp.Party  No. 2 filed written version inter alia denying the petitions allegations on all its material particulars.  The O.p No.1 has not appeared and not shown his interest to file counter , hence the O.p 1 was set exparte. It is submitted by the O.p 2 that the complainant has suppressed material information and has attempted to mislead this Forum  by giving incorrect information. The complainant has taken policy bond  IOB Health Care Plus from the O.P 1 and he personally filed the proposal form and also given  good health declaration. The premium shall be forfeited in the event of misrepresentation, misdirection or non disclosure of any material facts by the policy holder and non disclosure shall include  non  intimation  of any circumstances which may affect the insurance cover granted. On the verification of the documents and history sheet of the patient it revealed that the patient was having deceases prior to the date of proposal of the policy which is a violation of the terms and conditions of the policy  and suppression of facts. The O.ps have not caused any mental agony  or financial loss and rightly repudiated the claim  and hence pray to dismiss the proceedings with costs.

 

The Opp.Parties stated  that the complainant has suppressed the previous ailments but not given any documents to support their claim rather  as per the IOB Health Care Plus  Policy he is entitled to get the amount for medical expenditure and in fact the policy is continuing one from year to year and as such the plea taken by the O.p is not a consumer favour . As such the plea  of O.p 2 is rejected and O.P No.1 is directed to pay the amount claimed in the mediclaim policy. Hence, it is ordered.

                                                                     ORDER

                        The  Opposite Party  - 1 is   directed to  pay the  insurance    amount of Rs.15,545/-  through O.p No.2   before the forum with  compensation of  Rs.5,000/-  and  the O.p No.1 & 2 are directed to pay cost of  litigation of Rs.500/- each  to the complainant within one month from the date of receipt of this order, failing which the O.Ps are liable to pay  penal  interest  @  12%  p.a. on the above awarded amount till  the date of payment.

                        Pronounced in open forum today on this  26^th day of September,2015 under the seal and signature of this forum.

                         A copy of this order as per the statutory requirements, be forwarded to the parties    free of charge.

 

Member                                                                                               President

Documents relied upon:

By the complainant:

 

1. Book containing policy conditions of IOB Health Care policy
2. Letter dt.17.2.2014
3. Copy of policy bond
4. Claim intimation letter
5. Medical bill
6. Cash receipt

By the Opp.Party: Nil                                                                     President