DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, JHARSUGUDA
CONSUMER COMPLAINT CASE NO. 58 OF 2016
Bijay Kumar Nangalia (57 Years),
S/O: Late Shyam Sundar Nangalia,
RO: Hari Om Vihar, Near Tarini Temple,
PO/PS: Brajrajnagar, Dist: Jharsuguda, Odisha………...………………Complainant.
Versus
- SBI Life Insurance Co. Ltd.,
Represented through its Head (Claims)
Central Processing Center, Kapas Bhawan, Plot No.3A, Sector-10, CBD Belapur, Navi Mumbai ( MH)
- Managing Director,
SBI Life Insurance Co. Ltd.,Jharsuguda Branch,
At- Marwaripada, Back side of Sani Mandir,
PO/PS/Dist: Jharsuguda, Odisha.
- Ramprabesh Rai,
R/O: Mandalia, PO/PS: Brajrajnagar,
Dist: Jharsuguda, Odisha………..…….……………….…………..Opp. Parties.
Counsel for the Parties:-
For the Complainant Sri R.K. Pal,Adv. & Associates..
For the Opp. Parties Shri S.K. Dash, Adv & Associates.
Date of Order: 28.02.2017
Present
1. Shri S.L.Behera, President.
2. Shri S. K. Ojha, Member.
3. Smt. A. Nanda, Member(W).
Shri S. K. Ojha, Member : - In brief, the case of complainant is that, the complainant had insured himself along with his wife with the O.Ps. and taken a health insurance plan namely by paying yearly premium of Rs.15,949/- only since dtd. 24.11.2011 having sum assured of Rs.5,00,000/- only bearing policy No. 46003906207. As per the policy conditions the O.Ps. shall be liable to pay Daily Hospital Cash Benefit (DHCB) and Intensive Care Unit (ICU) benefit to the insured in case of any treatment or hospitalization during the policy period. The complainant
has paid the last premium on dtd. 29.12.2014 and the policy was enforced up to dtd.28.12.2015. Within the policy period the complainant met with an accident and sustained Sevier injury, registered a PS case bearing No. 260 dtd. 14.10.2014 at Brajrajnagar Police Station. Later he was shifted to Apollo Hospital, Bhubaneswar and admitted there from dtd. 15.10.2014 to 28.11.2014 within which he was admitted in ICU for about 23 days and in private care for about 22 days. The complainant claimed for insurance by submitting all the required documents but the O.Ps. repudiated the claim on dtd. 24.07.2015 on the ground that he was suffering from diabetes prior to the date of commencement of policy and the said facts was not disclosed at the time of signing of the contract of insurance, hence this case.
The O.P No.1 & 2 appeared and filed their written version jointly through their counsel after being noticed where the O.P.No.3 set ex-parte as he failed to either appear or filing his written version after being providing sufficient opportunities. The O.P.No.1 & 2 jointly admitted the fact of insurance but denied on any allegation imposed by the complainant and submitted that the complainant had suppressed some material facts at the time of signing of proposal form that he was not suffering the disease of diabetes but later it was found as per the discharge summary of the Apollo Hospital, Bhubaneswar the complainant was admitted to the hospital during the period from 09.09.2011 to 18.09.2011 due to diabetes mellitus, Dengue Fever and Oesophageal Candisiasis. The O.Ps. repudiated the claim of complainant due to non-disclosure of the facts by the complainant and prayed for dismissal of the case.
Heard the matter in length and gone thoroughly on case record with materials available. It is found that, the complainant had taken a Health Insurance Plan having plan “SBI Life-Hospital Cash” by paying annual premium of Rs.15,949/- only for Sum Assured of Rs.5,00,000/- only bearing policy No. 46003906207 commenced from dtd.29.12.2011. As per the policy condition, the premium paying term was 03 years, Daily Hospital Cash Benefit(DHCB) is Rs.5,000/- only, Intensive Care Unit (ICU) benefit is Rs.10,000/- only and Family Care benefit is Rs.10,000/- only for the complainant along with his wife Manju Nangalia. As per the letter dtd. 24.07.2015 the O.Ps. repudiated the said claim of insurance on the ground that the proposal of insurance dtd. 08.12.2011, the Life Assured had answered wrongly that he was not suffering from diabetes prior to the date of commencement of policy i.e. 29.12.2011 and signed the contract of insurance.
However, the complainant might have concealed the material facts at the time of signing the insurance proposal form that he was not suffering from the disease of diabetes but it is worth noting that, the cause of hospitalization and claiming for the medical treatment is whether caused by the said disease of “diabetes” or not ? But as per facts of the case, the complainant / insured met with an accident and sustained severe injury and it was upto such that, he had to get treatment at the Apollo Hospital, Bhubaneswar where he had to be admitted at ICU and private care for almost 45 days. Challenging on the same, the O.Ps. also submitted that as per the terms and conditions of the policy the benefits for hospitalization for 45 days i.e. from dtd.15.10.2014 to 29.11.2014 , would have been Rs.3,40,000/- ( ICU- 23 days x Rs. 1000 (+) Non ICU - 22 days x Rs.500/-), if the claim would have been accepted and not the sum assured of Rs.5,00,000/- only. The complainant claimed for total Sum Assured but failed to file the medical bills for actual expenditure incurred.
On the above observations and analysis as the hospitalization of the complainant is not due to the cause of disease “diabetes” but due to met with an accident and as per the policy condition the complainant is entitled to get relief. Hence, we are in considered opinion to allow the complaint petition of the complainant as per the calculation based on submission of the O.Ps. with compensation in form of order as follows;-
ORDER
The O.P.No. 1 & 2 are hereby jointly and severally directed to pay a sum of Rs.3,40,000/-(Rupees three lakhs forty thousand) only towards insurance claim amount along with pay a sum of Rs.20,000/- ( Rupees twenty thousand) only towards harassment, mental agony and cost of litigations to the complainant within 30 (thirty) days from the date of receipt of this order, failing which O.P. No.1 & 2 shall be liable for interest @10% on above mentioned awarded amounts till its realization.
Accordingly the case is disposed of.
Order pronounced in the open court today on this the 28th day of February’ 2017, copy of this order shall be communicated to the parties as per rule.
I Agree,
S.L.Behra, President A. Nanda, Member S.K.Ojha, Member
Dictated and corrected by me,
S.K.Ojha, Member
