Date of filing:- 20/10/2020.
Date of Order:-23/07/2024.
DISTRICT CONSUMER DISPUTE REDRESSAL COMMISSION
B A R G A R H (ODISHA).
Consumer Complaint No. 81 of 2020.
Suraj Kumar Agrawal, S/o Ashok Kumar Agrawal, R/o Swastik Machinery, NH-6, Near Railway Fatak, Ganesh Nagar, Bargarh, Odisha-768028.
..... ..... ..... Complainant.
-: V e r s u s :-
Star Health and Allied Insurance Company limited, Through its Branch Manager, Sambalpur, R/o 2nd Floor Quality Mansion, Nayapara, Sambalpur-768001.
..... ..... ..... Opposite Party.
Counsel for the Parties:-
For the Complainant :- Sri S.K.Dash, Advocate with associates.
For the Opposite Party :- Sri A.K.Dash, Advocate.
-: P R E S E N T :-
Smt. Jigeesha Mishra ..... ..... ..... ..... ..... P r e s i d e n t.
Smt. Anju Agrawal ..... ..... ..... ..... ..... M e m b e r (W).
Dt.23/07/2024. -: J U D G E M E N T:-
Presented by Smt. Anju Agrawal, Member(w):-
1) The case of the Complainant is that the Complainant is having a Family Health Optima Insurance Plan with the Opposite Party having Policy No.P/191214/01/2019/ 002098. For the aforesaid policy the Complainant has paid ₹ 17,736/-(Rupees seventeen thousand seven hundred thirty six)only towards premium, sum assured value of the Policy is ₹ 1,15,216/-(Rupees one lakh fifteen thousand two hundred sixteen)only, policy valid from Dt.13-01-2019 to Dt.12-01-2020. In the aforesaid policy the wife of the Complainant namely Chandini Agrawal was also insured having Consumer ID No. 105206592. On Dt.05-03-2019, the wife of the Complainant for low back paid went to Vikash Hospital, Bargarh, where she was treated and referred to National Institute of Mental Health and Neuro Sciences, Bangalore for further investigation. After investigation, as per advice of treating Doctor, the wife of the Complainant has undergone surgery on Dt.08-05-2019 and discharged from the hospital on Dt.25-04-2019. The Complainant has spent ₹ 1,15,216/-(Rupees one lakh fifteen thousand two hundred sixteen)only towards treatment and for the same has claimed the amount to the Opposite Party but the claim was rejected by the Opposite Party due to “Suppression of material facts by the Complainant”. The Complainant has further stated regarding the tumor, the fact was known to the Complainant on 05-03-2019 and to policy was obtained on 13-01-2019, no information has been suppressed by the Complainant. For the deficiency in service caused by the Opposite Party the Complainant filed complaint before this Commission praying that Opposite Party is directed to pay a sum of ₹ 1,15,216/-(Rupees one lakh fifteen thousand two hundred sixteen)only and ₹ 50,000/-(Rupees fifty thousand)only towards the deficiency in service and ₹ 20,000/-(Rupees twenty thousand)only towards litigation expenses to the Complainant.
2) The case of the Opposite Party is that the Opposite Party has filed its version and stated that the Complainant has taken the Family Health Optima Insurance Plan Policy vide Policy No.P/191214/01/2019/002098 for the period Dt.13-01-2019 to Dt.12-01-2020 covering the Complainant, his wife Chandini Agrawal and daughter Krishika Agrawal, but the insurance policy is subject to certain terms and conditions. From the claim documents submitted and from the prescription of Vikash Multi Specialty Hospital, Bargarh Dt.05-03-2019 the insured patient was suffering from low back pain and was facing difficulty in walking as per the discharge summary of National Institute of Mental Health and Neuro Sciences, Bangalore. As the insured has failed to disclose the above illness at the commencement of the policy, the claim of the Complainant has been repudiated. There lies no deficiency in service on the part of the Opposite Party.
3) Perused the documents filed by the parties and following issues are framed.
Issues
- Whether the Opposite Party is deficient in its service ?
- What relief the Complainant is entitled for ?
Issue No.1(one)
4) It is an admitted fact that the Complainant, his wife and daughter were insured with the Opposite Party vide policy No. P/19214/01/2019/002098. During the valid period of Insurance the Complainant's wife has undergone surgery in National Institute of Mental Health and Neuro Sciences, Bangalore and for the same has spent a sum of ₹ 1,15,216/-(Rupees one lakh fifteen thousand two hundred sixteen)only when the Complainant has claimed the Opposite Party repudiated on the ground “pre-existing disease”. The Opposite Party has stated that as per the discharge summary of the Hospital i.e. National Institute of Mental Health and Neuro Sciences, Bangalore, the Complainant's wife has difficulty in walking for the past one year which confirms that the insured patient is symptomatic of the disease “Neurofibromatosis”. At the time of issuing policy it was the duty of the Opposite Party to examine all insured persons to continue to policy. The Opposite Party failed to exercise his duty and received premium and when the Complainant lodged claim the Opposite Party became active repudiating the claim. Due to difficulty in walking and low back a common person cannot have an idea that it can lead to neurofibromatosis surgery. Prior to commencement of policy no treatment has been undergone by Complainant's wife regarding the aforesaid disease. As the policy was in force the Complainant's wife has undergone surgery and as policy terms the Complainant is entitled for the claim. Non settlement of claim when the policy is in force amounts to deficiency in service on the part of Opposite Party.
Issue No.2(two)
5) As discussed supra the complaint is entitled for relief claimed.
Accordingly the following order is passed.
O R D E R
6) The complaint is allowed on contest against the Opposite Party. The Opposite Party is directed to pay ₹ 1,15,216/-(Rupees one lakh fifteen thousand two hundred sixteen)only towards sum assured value along with 9%(nine percent) interest per annum from the date of repudiation i.e. 30-08-2019 to till date of this Order to the Complainant Further the Opposite is directed to pay Rs. 30,000/-(Rupees thirty thousand)only for deficiency in service and Rs.10,000/-(Rupees ten thousand)only towards litigation cost to the Complainant. All the above order to be complied within forty five days, failing which, the entire awarded amount shall carry 12%(twelve percent) per annum interest till realization.
7) Accordingly the order is pronounced in the open Commission to-day i.e. Dt.23/07/2024 and the case is allowed against the Opposite Party and disposed off.
Typed to my dictation
and corrected by me.
I agree, ( Smt. Anju Agrawal)
M e m b e r(w).
(Smt. Jigeesha Mishra)
P r e s i d e n t.
