Orissa

Cuttak

CC/142/2019

Surya Madhaba Panigrahi - Complainant(s)

Versus

Star Health and Allied Insurance Co Ltd - Opp.Party(s)

R K Pattanaik & associates

08 Jun 2022

ORDER

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

                                                                                 C.C.No.142/2019

Surya Madhab Panigrahi,

S/O:Purna Chandra Panigrahi,

At:House No.M/34,Manorama Estate,

Rasulgarh,P.O:Rasulgarh,Bhubaneswar,

Distg:Khurda                                                                                 ... Complainant.

        

                                                Vrs.

1.        The Managing Director,

Star Health and Allied Insurance Co. Ltd.,

1,New Tank Street,Valluvar Kottam High Rod,

Nungambakkam,Chennai-600034.

 

2.        Branch Manager,Cuttack Branch,

Star Health and Allied Insurance Co. Ltd.,

Plot No.1677(P)/1678(P),Holding No.608,2^nd Floor,

Gajanan Complex,Dolamundai,

P.O:Buxi Bazar,Cuttack-753001....Opp. Parties.

                       

Present:               Sri Debasish Nayak,President.

                                Sri Sibananda Mohanty,Member.

 

Date of filing:    05.11.2019

Date of Order:  08.06.2022

 

For the complainant:            Mr. R.K.Pattnaik,Adv. & Associates.

For the O.Ps.       :                  None.

 

Sri Debasish Nayak,President              

            Case of the complainant as made out from the complaint petition in nutshell is that the complainant had purchased a health insurance plan vide policy bearing No.P/191212/01/2017/003349  under “Family Health Optima Insurance Plan” on 22.11.16 from the O.P Company by paying a premium amount of Rs.19,740/- for the assured sum of Rs.5,00,000/- .  The policy was renewed as per the modified benefits and coverage’s on paying premium amounting to Rs.24,378/- dt.8.11.17 vide receipt No.1250004246 against policy No.P/191212/01/2018/003768.  Again it was subsequently renewed on 16.11.18 and the premium of Rs.24,378/- was paid vide receipt No.1250005347 against policy No.P/191212/01/2019/004839 and this policy was valid till 21.11.2019.  The complainant fell ill in the month of June,2018 for stone in CBD which was removed through surgical operation called ERCP on 19.6.18 thereby incurring an expenditure of Rs.50,000/-.  The said amount was not reimbursed even if the claim was made by the complainant vide claim No.0141599 dt.20.6.18.  Again in the month of January,2019, the complainant felt seriously ill and was under treatment for Cholangitis/Hepatolithiasis.  He was hospitalised in Asian Institute of Gastroenterology at Hyderabad under the treatment of Dr. D.Nageswar Reddy and Dr. G.V.Rao.  There were several investigations made and the complainant opted for cashless claim thereby submitting his policy bond in the hospital on 22.2.19 vide claim application no.CLI/2019/191212/0676467.  The complainant had incurred expenditure of Rs.30,000/- but surprisingly his claim was rejected vide letter dt.24.2.19 on the grounds that the said disease has been incorporated as per the existing disease in the policy schedule.  The complainant after receipt of the said rejection letter from the O.P had requested the Chief Medical Officer of Asian Institute of Gastroenterology to give him the certificate as regards to the allegation of pre-existing disease and copy of the certificate as obtained has been affixed vide Annexure-5.  As it appears, when the repeated persuasions of the complainant was rejected by the O.Ps on different pleas the complainant having no other way out had to approach this Commission claiming an amount of Rs.1,00,000/- towards the mediclaim policy in order to meet the actual expenses at the hospital and has claimed compensation to the tune of Rs.1,00,000/- from the O.Ps towards his mental agony and harassment.  The complainant also prayed for a sum of Rs.20,000/- towards the cost of litigation.

            He has filed a series of documents in support of his case.

2.         On the other hand, the O.Ps have not contested this case for which they have been set exparte vide order dt.19.4.2022.

3.         The points for determination in this case are as follows:

i.          Whether the complainant has any cause of action to file this case?

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

            iii.        Whether the complainant is entitled to the reliefs as claimed?

Point No.2.

            Out of three points for determination, point no.2 being an important one is taken up first for consideration.  On perusal of the series of documents, the contents of the complaint petition which have remained unchallenged from the side of the O.Ps, it appears to this Commission that definitely there was deficiency in service and this point accordingly goes against the O.Ps of this case.

Point No.1 & 3.

            From the above findings, it can well be said here that the complainant had a definite cause of action to file this case.  Accordingly, the complainant is entitled to the reliefs as claimed by him.  Hence it is so ordered;

                                                                       ORDER

            The case is decreed exparte against the O.Ps.  The O.Ps are found to be jointly and severally liable here in this case.  The O.Ps are directed to immediately reimburse the total expenses of the complainant to the tune of Rs.1,00,000/- within a month hence.  The O.Ps are further directed to pay a sum of Rs.60,000/- towards his mental agony and harassment and a sum of Rs.20,000/- towards the litigation cost to the complainant.  This order is to be carried out within a month hence.

Order pronounced in the open court on the 8^th day of June,2022 under the seal and signature of this Commission.

                                                                                                                                                                                                                                                 

                                                                                                                              Sri Debasish Nayak

                                                                                                                                        President

                                                                                                                       

                                                                                                                             

                                                                                                                         Sri Sibananda Mohanty

                                                                                                                            Member.