Brief fact of this case is that, the complainant had purchased one family Health Insurance Policy from OP.No.1 Insurance Company through its agent OP.No.2 and paid premium of Rs.21,920/- namely “Happy Family Floater 2015 Policy” bearing No.345505/4B/2021/1290 . The policy is assured a sum of Rs.3,00,000/- and continued it till date. The policy is annually renewed and the present Insurance period is valid from 25.01.2021 to 24.01.2022. The Policy is covered the family members of the complainant such as the petitioner herself, husband, son & daughter. Unfortunately, the husband of the complainant Sri Bhramarbar Mishra suffered from AVN Femoral Head (Rt) and admitted in General Nursing Home, Mangalabag, Cuttack on dt.25.01.2021. The husband of the complainant had to stay in hospital from 25.01.2021 to 06.02.2021 for Operation and treatment. The hospital supplied a bill amounting to Rs.2,08,500/- and after payment of this amount to the hospital on that date the husband of the complainant was discharged from the hospital on 06.02.2021. Thereafter the complainant submitted the claim form and all the relevant and connected papers of the Operation and hospitalisation and payment made in original and photocopy of X-ray report etc. to the OP.No.1 Oriental Insurance company and subsequently the Op.No.1 submitted to Op.No.2 along with the documents for settlement of claim of Rs.2,08,500/- on 12.03.2021. Although more than five months has elapsed in between the Ops have neither paid the amount nor made any positive response in this regard for which the complainant suspect that the Ops are negligent in paying the settlement amount which is deficiency of service causes the complainant suffers from mental agony and also financial loss. The total claim amount is Rs.2,20,500/- which includes(1) amount already paid of Rs.2,08,500/-,(2) Form Mental agony as Rs.5,000/-(3) Financial loss as Rs.5,000/- and (4) cost of litigation of Rs.2,000/-. Hence, the complainant prayed before the Hon’ble Forum to pass necessary direction to both the Ops to pay an amount of Rs.2,20,500/- with interest within a stipulated period and any other relief as deemed proper.

The complainant relies upon the following documents:

1. Photocopy of Health Insurance Policy.
2. Photocopy of payment receipt of Rs.2,08,500/-
3. Photocopy of Discharge certificate of the Nursing Home.

On the above complain, the case is admitted and notice issued to the Ops for filing written version. In their written version the OPs stated that since the claim of the complainant was closed ”No Claim” after due application of mind and after taking all the relevant factors in to consideration, question of deficiency in service on the part of Ops Insurance company does not arise at all. As such, the complaint petition is not maintainable and the same is liable to be dismissed. That, after getting the claim intimation letter on dt.28.02.2021 fromthe complainant, OP No.1 has communicated to Op.No.2 with some relevant documents to process the claim file. Then Op.No.2 processed the file and examined. During the examination of records it is found that some additional documents are required for processing the claim. Thereafter the OP No.2 has communicated query letters to the petitioner to submit the following documents such as (1)Original Tax invoice or implants with sticker.(2) Medicine details of Rs.20,000/-(3) Declaration of injury with date(4) Detail break up of Rs.55,000/- as per the bills submitted by General NursingHome, Cuttack. After receiving all query letters the complainant remained silent and did not comply the above said required documents for process and settlement of the claim. At last OP.No.2 has communicated one final query letter to submit the above documents within 15 days of notice in case of non-compliance to close the claim. But the petitioner did not comply required documents as sought for by the OP.No.2 within the stipulated period on the other hand the complainant has filed this case without having any cause of action. Thereafter OP.No.2 has communicated one letter dt.12.07.2022 to Op.No.1 Oriental Insurance Co.Ltd. Stating that Op.No.2 is going to close the claim case in system due to non-submission of query reply in time. The complainant should have gone through the terms and conditions of the policy certificate which comes to her knowledge regarding legal and equitable basis of her claim. The Ops have already specifically clarifiedthe actual facts of the case in the above Para.So there is no deficiency of service on the part of Ops Insurance Company and the case filed against the Ops is liable to be dismissed. That, the claim of the complainant is baseless without anylegal and equitable basis. Hence prayed that, the learned commission be pleased to exempt the Ops Insurance Company from payment of compensation to the complainant in the interest of justice.

The OP relies upon the following documents:-

1. Photocopy of claim intimation of the petitioner.

2. Photocopy of Policy certificate.

3. Photocopy of intimation letter on dt.12.03.2021.

4. Photocopy Query letters (1^st query, 2^nd query,3^rd and final query)

5. Photocopy of Intimation letter of Op.2 to Op.1 regarding Non-compliance. 

On the above pleadings the following issues are framed to decide the case.

1. Whether the case is maintainable?
2. Whether any cause of action arises on this case?
3. Whether Ops have made any deficiency of service?
4. Whether the complainant is entitled to get any relief sought for? 

FINDINGS

All the issues are interlinked with each other. So they are discussed jointly to decide the case. It is a case of health Insurance, the OP Insurance company has closed the claim as “No Claim” due to non-submission of following documents(1) Original Tax invoice of implants with sticker(2) Medicines details of Rs.20,000/-(3) Declaration of injury with date(4) Details break up of Rs.55000/-. The OP Insurance Company submits that the petitioner did not compliedand submitted the required documents and filed this case without having any cause of action. The Insurance Company has not made any deficiency of service. But, on the other hand the complainant submits all relevant documents supplied by the General Nursing Home, Cuttack and the OP has to enquire in to the matter through General Nursing Home, Cuttack. It the duty of the OP Insurance company also to collect the relevant documents through petitioner as well as through General Nursing Home Cuttack. In this case the OP Insurance company remained silent only issuing a letter to submit the relevant documents. In this case the complainant became helpless for non- cooperation of the Insurance Company. The complainant has filed the Money receipt of Rs.2,08,500/-, prescriptions and Xerox copy of X-ray. A bill of details regarding treatment which shows that the Nursing Home has received Rs.2,08,500/- .

So this commission feels that OP Insurance Company has made negligence declaring the claim as “No Claim”. The complaint petitions filed by the complainant with grounds are affirmative. So this case is maintainable and the complainant is entitled to get the relief prayed for,

ORDER

            The complaint petition is allowed. The OPs Insurance Company are directed to pay the complainant of Rs.2,08,500/- as claimed and Rs.10,000/- for mental harassment and cost of litigation within 45days from the date of this order. If the Ops failed to comply the order within the stipulated period the total amount of Rs.2,18,500/- shall carry 9% interest per annum from the date of filing till realisation.