Orissa

Rayagada

CC/398/2015

Sri Chittaranjan Narendra - Complainant(s)

Versus

Peramount Health Services - Opp.Party(s)

Self

20 Sep 2016

ORDER

DISTRICT   CONSUMER  DISPUTES REDRESSAL    FORUM, RAYAGADA

                                           C.C. Case  No.398/ 2015

 P R E S E N T .

Sri Pradeep Kumar Dash, LL.B,                               President.

Sri Gadadhara Sahu,B.Sc.                                      Member

Sri  Chitta Ranjan Narendra Jit Singh, S/o Sri Umakanta Narendra Jit Singh, Room No.1,Nagavali Hostel, JKPM Campus, At/Po Jay Keypur,Dist. Rayagada, Odisha.                                                                                                              …….Complainant

                                                            Vrs.

1.  Paramount Health Services (TPA) Pvt. Ltd.,,D-39,Okhla Industrial Area,Phase-I, New Delhi-110020,Delhi-110020.
2.  JK Paper Ltd., Unit-JKPM, Jay Keypur,Dist.Rayagada,765017, Odisha, Represented by DGM (Administration) 
3. Chief Regional Manager, National Insurance Co.Ltd.,6^th Floor, IDCO Tower, Janapath, Bhubaneswar, Odisha.                                                                                                                                    …..…..Opp.Parties

Counsel for the parties:

For the complainant: In Person

For the O.P 1 & 3  : Sri K.Ch.G.S.Kumundan,Advocate,Rayagada.

For the O.P 2 : Set Exparte

                                                            JUDGMENT

                        The facts of the complaint  in brief is that the complainant  has done a medic claim insurance policy bearing Policy No.PHS ID No.2153411 with OP 1  in favour of his mother and in due course of time his mother  got admitted to Aditya Care Hospital Bhubaneswar on 18.07.14 for chest pain and after check up  she needs urgent surgery accordingly  the complainant approached the  OP 1  through the  concerned hospital for cashless treatment but the OP 1 denied for cashless treatment citing the ground that the disease was preexisting and later on  the  OP 1 fully convinced and advised the complainant to go ahead with treatment  and after getting clarification from concerned doctor that disease is not preexisting  and as per the direction of the OP 1 surgery and treatment was carried out   at Aditya Care Hospital, Bhubaneswar from 18.07.14 and patient was discharged on 26.07.14 and as per advised by Op 1  the complainant submitted all original documents pertaining to treatment along with discharge  certificate bills etc. to OP 1 through OP 2 for reimbursement of Rs.66,000/-  but unfortunately the claim is not reimbursed  so far after several communication by email  though OP 2 and  complainant  and the OP 1 finally rejected the claim stating that the disease is preexisting and not fit for claim. The denial of claim is quite arbitrary and  hence  the case of the claim of the complainant  is a clear case of breach of contract . Hence prayed to direct the OP 1 to reimburse the claim of Rs.66,000/- and give such relief  as the court deems fit and proper. Hence, this complaint.

                        Being noticed, the O.p 1, & 3     appeared and filed their written version and OP 2neither appeared  nor filed written version as such the Op 2 were set exparte.  It is stated by the O.p No. 1,  that  the OP 1  is a Third Party Administrator to the National Insurance Co. Ltd.  The OP 1 received cashless claim from hospital  and after primary scrutiny, the OP1 unable to sanction cashless benefit for the said hospitalization  as the ailment is pre existing and as per policy clause pre existing disease is cover after four claim free policy period,  hence the claim is repudiated.

                        It is submitted  by OP 3 that the complaint petition filed by the complainant is not maintainable since the same has not been filed by his mother who requested for cash less treatment. The OP 3 is neither handling the claim nor in any way aware of the details of the claim and in absence of policy number and other particulars of the policy, the OP 3 is not tenable in law. After filing the policy or other details the same will be examined through the TPA  on its merit as to the denial of cash less treatment by them and counter suitably will be filed and hence prayed to dispose the petition preliminary.

                                                            FINDINGS

                        It is cardinal principle of insurance law that the insurer is in the position of a trustee as it is managing the common fund  for and on behalf of the community of the policy holders. When a person taken insurance policy to cover the envisaged risk, he does not take it for commercial purpose, policy is only for indemnification and actual loss. It is not intended to generate the profit. So consumer complaint for deficiency on the part of insurance company can lie in the consumer though the appellant may be engaged in some sort of business.

                        Effort of the insurance company should not be  to find out a ground to reject the claim. The efforts should be that how the consumer can be benefitted by interpreting the terms of a contract or provisions of a statute in beneficial manner. Insurance company can repudiate the claim of the insured in case where the breach of policy condition is fundamental or  material breach so as to vitiate the insurance contract.

                        In this case the OP 1 received cashless claim. The OP 1 is a  Third Party Administrator to the OP 3 – National Insurance  Co. Ltd.  As per the advise of the OP 1  the complainant submitted all original documents pertaining to treatment along with discharge certificate  bills etc.  Once the insurance company had accepted the documents at the time of insurance of the insurance  cover and had charged premium amount accordingly. Therefore it could not claim that its value on total loss basis on the date of treatment have come down to almost half.

                        The OP 1 finally rejected the claim stating that the disease is preexisting and not fit for claim. The denial of claim  is quite arbitrary. In case  breach is irregular or merely contributory there is provision for settlement  as non standard according to the guidelines.

                        Insurance company should settle the claim within three to four months of the claim filed  otherwise liable to pay interest at 9%  per annum  after the months of the report. But after  approaching of since last two years the Ops  have not settled the issue. In view of the discussion above and as such the complainant is  entitled to get the claim amount.

                        We have gone through the complaint petition and documents available in the record. The forum by relying upon a citation passed by “ National Commission, New Delhi in the New Indie Assurance Co. Ltd. Vars. M/s Sukhadham India Pvt. Ltd. 2011(1) CPR 191 Such as “; “ Insurance Company must settle the claim  without delay”. In the light  of the above decision of law we allowed the case. Hence, it is ordered.

                                                            ORDER

                        In the result the complaint petition is allowed on contest. We ordered the OP 1 & 3 to pay the claim amount of the complainant i.e. Rs.66,000/- to the complainant and to pay interest of  @ 9% per annum on the entire amount from the date of respective claim till realization. We are further ordered to pay Rs.3,000/- each by the OP 1,2 & 3 towards cost. All the payment must be made through the Forum only.

                        Pronounced in open forum today on this 5^th day of  October,2016 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. copy  of   death certificate
2. copy of legal heir certificate
3. copy of  service book of the deceased
4. copy of affidavit

By the Opp.Party: Nil

 

                                                                                                 President