DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD

Dated this the  25^th day of May, 2023

Present      :   Sri. Vinay Menon V., President

                  :  Sri. Krishnankutty N.K., Member                                Date of Filing: 10/01/2022  

                         CC/5/2022

Yasoda C.H.

W/o.Dr.Govindan (late),

8/359, Shivananda Ashramam Road,

P.O.Kallekulangara,

Palakkad                                                                -                       Complainant

       (By Adv.K.Dhananjayan)

                                                                                                Vs

1. M/s.United India Insurance Co.Ltd.

Bank Assurance Division,

D.O. IV, 7^th Floor, United India Tower,

Basheer Bagh, Hyderabad – 500 029

2. M/s.United India Insurance Co.Ltd.

Bank Assurance Division,

D.O. IV, 7^th Floor, United India Tower,

Basheer Bagh, Hyderabad – 500 029

Rep.by M.D./Manager/ Authorised Signatory

3. M/s.Health Insurance TPA of India Ltd.,

2^nd Floor, Majestic Omania Building,

A-110, Sector 4, Noida, U.P. – 201 301

4. M/s.Health Insurance TPA of India Ltd.,

2^nd Floor, Majestic Omania Building,

A-110, Sector 4, Noida, U.P. – 201 301

Rep.by M.D./Manager/ Authorised Signatory

5. Manager, Union Bank of India,

Dr.Pattabhi Bhavan,

Saifabad,  

Hyderabad – 500 004                                     -                       Opposite parties

             (Ops 1&2 by Adv.Ajitha A

              OPs 3 to 5 Exparte)

O R D E R

By  Sri. Vinay Menon V., President

1. Complainant is a beneficiary of medical insurance policy issued by first opposite party from 2015 onwards. During the time of availing policy covering 2020 to 2021 she had topped up her policy.  She had to undergo treatment for various ailments during this period and had to incur Rs.3,50,000/- in various hospitals. The opposite parties failed to honour her claim. Aggrieved thereby this complaint is filed.
2. Opposite parties 1 & 2 entered appearance but failed to file version within the statutory period and the version was rejected. Aggrieved thereby they filed Review Application as RA 132/2022 seeking review of the order of rejection. RA was dismissed by this Commission. Challenging the order of dismissal of this RA, the contesting OPs filed Revision Petition before the Hon’ble SCDRC as RP 91/2022, which was also dismissed upholding the order of this Commission. Thereby they were precluded from contesting the dispute.

3. Opposite   parties 3 to 5 did not enter appearance and were set exparte.

4. The complainant filed proof affidavit and marked Ext.A1 to A5 in support of their claims. Ext.A1 is  a consolidated bill dated 11/7/2020. Ext.A2 is a communication dated 25/8/2020 showing the sum insured as Rs.1 lakh. Ext.A3 is a copy of the policy covering 9/6/2015 to 8/6/2016. Ext.A4 is an identity card issued in favour of the complainant. Ext.A5 is a discharge summary issued from Rajeev Co-operative Hospital.

5. It is true that the OPs 1 & 2 are not able to contest the dispute. But it is incumbent upon the complainant to prove that she has a prima facie case. Merely because of the opposite party failed to file their version within the statutory period, allowing the complaint as being uncontroverted will only lead to absurdity.

6. Complainant’s case is that she was having a top up policy during the period 2020 to 2021. In support of her pleadings she has produced Ext.A2.

Ext.A2 is a communication from O.P. 3 addressed to complainant showing the details of the policy cover. Covering period is from 9/6/2020 to 8/6/2021. Two types of policy numbers are seen in Ext. A2. One is Arogyadhaan Policy No. and the other is Super TopUp Policy No. Arogyadhaan Policy No. is 0504002820P102561452. Arogyadaan Sum Insured is Rs. 1,00,000/-. But it can be seen that she had not opted for Super TopUp Policy. The schedule also is blank under the heading “Super TopUp UHID”. Super TopUp Sum Insured is shown as “Rs. 0”. The sum assured is shown as Rs.1 lakh.

Ext.A3 is the terms and conditions of Arogyadaan Policy.This is a Super TopUup policy. But the period of policy is from 9/6/2015 to 8/6/2016. The complainant has not produced the policy terms and conditions covering the relevant period from 9/6/2020 to 8/6/2021.

1. The opposite parties 1 & 2 shall  consider the claim form of the complainant, if she files any within 45 days of receipt of a copy of this order. The OP shall consider the claim so filed in accordance with the policy that was in force during the relevant period and shall pay the admissible amount within 30 days of receipt of such claim.
2. If the opposite party has already received a claim from the complainant, they shall pay the admissible amount within 30 days of receipt of this order.
3. If the O.P.s had already received a claim from the complainant as contemplated under  eventuality (b) and if the opposite parties 1 & 2 had not already replied to the complainant by way of a written communication before institution of this complaint,   the complainant shall be  entitled to interest @10% from the date of filing of this complaint till date of handing over of the admissible amount.
4. If payment is in accordance with clause (c), the complainant will be entitled to a compensation of Rs.25,000/- and a cost of Rs.10,000/-.
5. Otherwise, the complainant will not be entitled to compensation or cost.

                  Pronounced in open court on this the 25^th day of May, 2023.    

                                                                                           Sd/-

                                                                                                Vinay Menon V

                                                      President                                                     

        Sd/-                                                            

Krishnankutty N.K.

                                                                                                      Member

APPENDIX

Exhibits marked on the side of the complainant :  Nil

Ext.A1 – Copy of Consolidated bill dated 11/7/2020.

Ext.A3 - Copy of the policy covering 9/6/2015 to 8/6/2016.

Ext.A4 – Copy Identity card issued in favour of the complainant.

 Exhibits marked on the side of the opposite party:  Nil

Court Exhibit:  Nil

Third party documents:  Nil

Witness examined on the side of the complainant:  Nil

Witness examined on the side of the opposite party:  Nil

Court Witness: Nil

NB : Parties are directed to take back all extra set of  documents submitted in the proceedings in accordance with Regulation 20(5) of the Consumer Protection (Consumer Commission Procedure) Regulations, 2020 failing which they will be weeded out.