Orissa

Cuttak

CC/7/2019

Mohammad Anamul Haque - Complainant(s)

Versus

Sr.Divisional Manager ,United India Insurance Co Ltd - Opp.Party(s)

U N Sahoo

03 Dec 2022

ORDER

IN THE COURT OF THE DIST. CONSUMER DISPUTES REDRESSAL COMMISSION,CUTTACK.

       C.C.No.7/2019

Mohammed Anamul Haque,

Plot No.2C/178,Sector-9,C.D.A,

Cuttack-753014.                                                                   … Complainant.

 

                                                                Vrs.

1.              The Sr.Divisional Manager,UII Insurance Co. Ltd., CollegeSquare, Cuttack.

 

2.                   United India Insurance Company Ltd.,

Division Office 8,Union Co-Op Insurance Building,

5^th Floor,23^rd Sri P.M.Road,Fort,Mumbai-400001.

 

3.                  Managing Director,

United India Insurance Co. Ltd.,

24,Whites Road,Chenai-600014.

 

4.                  Family Health Plan Insurance TPA Limited,

Ground Floor,Srinilaya,CyberSpazio,Rod No.2,

BanzaraHills,Hyderabad-500034.

 

5.                 Family Health Plan Insurance TPA Limited,

16/2 Lake View Road,Kolkata-700029.

 

6.                 The Chief Manager(HR),

SBI,ZonalOffice,Bhubaneswar.                                       ... Opp. Parties.

 

 

Present:               Sri Debasish Nayak,President.

                                                Sri SibanandaMohanty,Member.

 

               Date of filing:     09.01.2019

Date of Order:    03.12.2022

 

For the complainant:          Mr.U.Sahoo,Adv.& Associates.

For the O.PsNo.12 & 3:      Mr. B. Dasmohapatra,Adv. & Associates.

For the O.Ps no.4 & 5:                      None.

For the O.P no.6:                   Mr. P.V.Balakrishna,Adv& Associates.

 

Sri Debasish Nayak,President.                        

           Case of the complainant as made out from the complaint petition in short is that had opted for Group Mediclaim Policy from the O.Ps vide Policy no.1202002817P 115010080.  From 2.2.18 to 4.5.18 the complainant had undergone treatment at his home under the prescription of the physician and had incurred expenses to the tune of Rs.2564/- which he had claimed from the O.Ps mentioning therein to pay him the balance after deducting Rs.357/- towards his treatment at Eye Hospital,  Cuttack. But inspite of several reminders the said claim of the complainant was not settled by the O.Ps.  He had paid the premium amounting to Rs.21,170/- which was debited from his account at S.B.I,Bidanasi Branch Cuttack and also the complainant being a retired employee of the State  Bank India, the said SBI had also paid premium for the complainant amounting to Rs.12,000/-.  Thus, when the claim of the complainant was not settled, he had to file this case before this Commission claiming the amount of Rs.2564/- alongwith interest thereon @ 12% per annum with effect from 7.8.18 till the total amount is quantified further, for compensation of Rs.3000/- towards his mental harassment and also furtherfor a sum of Rs.3000/- towards the cost of his litigation. The complainant has also prayed for any other reliefs as deemed fit and proper.

           He has filed copies of several documents in order to prove his case.

2.        Out of the six O.Ps as arrayed in this case, having not contested this case, O.Ps no.4 & 5 have been set exparte vide order dt.27.6.19.  However, O.Ps no.1,2,3 & 6 have contested this case but out of them O.P no.6 has filed his separate written version whereas O.Ps no.1,2 & 3 have conjointly filed their written version.

           According to the written version of the O.Ps no.1,2 & 3, the case of the complainant is not maintainable and is bad for non-joinder and mis-joinder of necessary parties.  According to these O.Ps, after receiving the claim of the complainant on enquiry they found that the complainant had undergone treatment as outpatient basis which, as per the listed procedure in the terms and conditions of the insurance policy as availed by the complainant is not claimable being not covered.  It is for this, the claim of the complainant was repudiated.

           As per the written version of O.P no.6, the claim of the complainant against O.P no.6 is not maintainable since because they have no role in the dispute in-between the complainant and the other O.Ps.

3.         Keeping in mind the averments as made in the complaint petition and the contents of the written version of the  O.Ps, this Commission thinks it proper to settle the following issues in order to arrive at a proper conclusion.

i.          Whether the case of the complainant is maintainable?

ii.         Whether there was any deficiency in service on the part of the O.Ps?

iii.        Whether the complainants are entitled to the reliefs as claimed ?

Issue No.ii.

Out of the three issues, Issue no.ii being the most pertinent issue is taken up first for consideration here in this case.

Admittedly, the complainant had been treated as an outpatient by remaining at his home.  It is the claim of the O.Ps no.1,2 & 3 that treatment as an outpatient as undergone by the complainant and claim thereof is not covered as per the terms and conditions of the policy availed by the complainant from them.  In this regard the complainant has no say.  On perusal of copies of the policy papers as available in this case record, it is also noticed that nowhere there is mention about the reimbursement of the insured if treated as an outpatient.  Thus, this Commission finds no deficiency in service on the part of the O.Ps.

Issues no.i& iii.

From the discussions as made above, it can never be said here that the case as filed by the complainant is maintainable and the complainant is entitled to any of the reliefs as claimed by him.  Hence it is so ordered;

ORDER

Case is dismissed on contest against O.Ps no.1,2,3 & 6 and exparte against O.Ps no.4 & 5 and as regards to the facts and circumstances of the case without any cost.

Order pronounced in the open court on the 3^rd day of   December,2022 under the seal and signature of this Commission.     

                                                                                                                                Sri Debasish Nayak

                                                                                                                                            President

                       

                                                                                                                                                                Sri Sibananda Mohanty

                                                                                                                                            Member