SRI BIJOY KUMAR DAS,PRESIDENT-

                        Deficiency in service in respect of Illegal repudiation of claim under health insurance policy are the allegations arrayed against the Opp.Parties.  

2.                     Complaint, in brief reveals that, being persuaded by OP No.2 & 3, the agent and the  Sales Manager of Star health and Allied Insurance Co.Ltd.,complainant took a health insurance policy on dtd.14.03.2017 by paying a premium amount of Rs.17,319/- and obtained the policy bond bearing No.P/191200/01/2017/008442. The said health insurance policy was valid from dtd.14.03.2017 to dtd.13.03.2018. It is stated that complainant faced an accident on dtd.10.11.2017, while playing Badminton as a result his left side DM/Tendoachilis Avulsion was teared for which the complainant was hospitalised in Seva Hospital/Nursingh Home,Cuttack on dtd.13.11.2017 and remained under treatment as indoor patient till dtd.28.11.2017. During the period of Hospitalization, complainant has to undergone for reconnection of the teared tendon. It is also stated that prior to the operation complainant took advise of and consulted different specialist including super specialist orthopedic doctor Mr. Dey of AMRI Hospital, Bhubaneswar. Complainant during hospitalization intimated the OP No.2 & 3 about the incident on dtd.13.11.2017, who visited the hospital and verified the facts. It is alleged that on dtd.15.12.2017 when the complainant submitted all the bills amounting of Rs.1,11,258/- of his treatment and ancillary expenses to OP No.2 through OP No.3 for the reimbursement, the OP-Insurance Company repudiated the claim on absurd grounds and the repudiation of the claim of the complainant is deficiency in service of the Ops, which gave financial loss and mental agony to the complainant and his family members. The cause of action of the instant case arose on dtd.14.03.2017, when the complainant took the policy and on dtd.13.11.2017, when the complainant was hospitalized at Seva Hospital,Cuttack for operation and lastly on dtd.28.02.2018 when the OP-Insurance Company sent his repudiation letter to complainant through mail. Accordingly, complainant prayed this Forum to issue direction to Ops for release of Rs.1,11,258/- as settlement of claim amount and Rs.1 lakh as compensation for mental agony.      

3.                    Though Notice was served  to the Ops by Regd.Post with A.D. through  this Forum and as per postal track consignment the notice was received by the Ops on dtd.24.03.2018, but Ops did not prefer to appear into the proceeding, hence set ex-parte by this Forum vide Order No. 8 dtd.28.06.2018.

4.                     Heard the ex-parte submissions advanced by the complainant who present physically and perused the documents filed into the dispute. Complainant to substantiate his case filed attested Xerox copies of policy issued by Star Health and Allied Insurance Company Ltd., attested Xerox copy of premium paid money receipt, attested Xerox copy of medical prescription of Dr. S.Bhuyan and Dr. P.C.Dey of AMRI Hospital,Bhubaneswar, attested Xerox copies of Discharge certificate, bills and money receipts granted by Seva Hospital,Cuttack,attested Xerox copies of Cash Memo in support of purchase of Medicines, attested Xerox copy of total expenditure of hospitalization and letter of repudiation dtd.28.02.2018 issued by OP-Insurance Company,. During course of hearing complainant attracted the attention of the Forum on the Memo filed by complainant himself before this Forum on dtd.07.04.2018 stating that on receipt of mini statement, complainant came to know that  the OP-Insurance Company has credited an amount of Rs.68,699/- to his S/B Account on dtd.06.04.18 operated at SBI,Main Branch,Kendrapara. Complainant further submits that, protesting on the release of quantum of claim amount, intimate the fact before  this Forum as the matter is pending sub-judice before the Forum.

                        On the submissions and presentation of documents it is clear that the plea taken by the OP-Insurance Company and grounds of repudiation of claim of complainant  is not accepted or not the subject matter of the dispute as certain amount has already been released to the complainant-insured by admitting the facts of hospitalization of the complainant by the OP-Insurance Company. Now this Forum has to decide whether amount of Rs.1,11,258/- as claimed by the complainant-insured  is to be paid by OP-Insurance Company or not ? Complainant in order to justify his claim of hospitalization files bill of SEBA Hospital,Cuttack amounting of Rs.80,300/- alongwith its money receipt. The cash memos showing payment of Rs.27,958/- towards purchase of medicines, and the expenditure  for  the said purpose appears to be genuine and reasonable as  the medicines purchased by the complainant being prescribed by Dr. Ranjan Singh the treating Surgeon. There is no reason to disbelieve such amounts as the same is not challenged anyway by the Opp.Parties.  In addition to this complainant claims Rs.3,000/- towards to and fro charges of Ambulance/Taxi from Kendrapara to Cuttack and back. But no such money receipts/bills/vouchers  are presented before this Forum to accept the version of the complainant towards reimbursement of travel expenses. Hence, the complainant is entitled to receive  an amount of Rs.80,300/- + Rs.27,958/- = Rs.1,08,258/-.(Rupees One lakh eight thousand two hundred fifty eight)only. As per the Memo of the complainant dtd.07.04.2018 Ops have already paid Rs.68,699/- and the balance amount to be paid by the OP-Insurance Company is for   Rs.1,08,258/- ­- Rs.68,699/- =Rs.39,558/-. The complainant is entitled to receive further amount of Rs.39,558/- from the OP-Insurance Company towards settlement of his claim for hospitalization/treatment.  

                   A common man of this country like complainant opts for a health insurance policy to safeguard himself and his  eligible family members of the policy, occurs due to health related problems, if such type of attitude is taken by the OP-Insurance Company to settle the health insurance claim, the purpose of taking the policy will be defeated. We unanimously, after due consideration to the facts and law liable the Ops for deficiency in service.

                     Having observations reflected it is directed that OP-Insurance Company shall release an amount of Rs.39,558/- alongwith 6 per cent simple rate of interest calculating from dtd.13.03. 2018 to till its realization and to pay Rs.2,000/-(Rupees Two thousand)only as cost of litigation. The ordered amount is to be paid together by the OP-Insurance Company within one month of receipt of this order, failing which 9 per cent interest will be charged for the delayed period.

            The complaint is allowed in part on ex-parte with cost.  

                    Pronounced in the open Court, this the 31st July,2018.                 

                         I,agree.   

                           Sd/-                                                 Sd/-

                     MEMBER                                    PRESIDENT