Orissa

Debagarh

CC/2/2018

Rajendra Goel, aged about 53 years, S/O-late Ram Kumar Goel - Complainant(s)

Versus

The Branch Manager, Canara Bank - Opp.Party(s)

07 Aug 2018

ORDER

BEFORE THE COURT OF THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, DEOGARH.

CD Case No- 02/2018.

Present-       Sri Dipak Kumar Mahapatra, President, Smt. Jayanti Pradhan, Member (W) and Smt. Arati Das, Member.

 

Rajendra Goel, aged about 53 years,

S/O-Late Ram Kumar Goel,

At-Patarasahi, Ward No-5,

P.O/P.S/Dist-Deogarh.                                                                                               …       Complainant

                                        Versus

1.        The Branch Manager,

CANARA Bank,

Pradhanpat Road, Deogarh,

PO/PS/Dist-Deogarh.

2.        The General Manager,

Appolo MunichHealth Insurance Company Limited,

Unit No.3, 2^nd Floor,501/1741/1845, Kharavelnagar,

                  Janpath, Bhubaneswar-751007, Odisha

3.         The Managing Director,

       Kalinga Hospital Limited,

        Chandrasekharpur,

       Bhubaneswar -753023, Odisha.   

4.          The General Manager,

Appolo MunichHealth Insurance Company Limited,

Central Processing Centre,

Plot No-404-405,Udyog Vihar,

Phase-III, Gurgaon-122016, Haryana.                                                          …       Opposite Parties.

 

 

            For the Complainant         : -        Nemo

            For the Opp.Party-1           :-        Sri S.Mishra. Advocate.

            For the Opp.Party-2&4     :-         Sri R.LPradhan & B.K.Purohit,Advocate  

            For the Opp.Party-3          :-         None.

      

            DATE OF HEARING: 23.07.2018, DATE OF ORDER: 07.08.2018.

Sri Dipak Kumar Mahapatra-Brief facts of the case are that the complainant is a policy holder of O.P-2 for a Easy Health Insurance Policy with cash less benefit. Due to illness the Complainant admitted in the Hospital of O.P-3 and applied for cashless benefit which was denied by O.P-3 for he has to pay the expenses in cash. After being released from the hospital the complainant being aggrieved file a case against to the O.Ps where the O.P1 claimed having no role in the settlement of insurance policy. O.P-2&4 have repudiated the cashless request as to non submission of required document during specified time for cashless facilities. The claim has been settled with a reimbursement of Rs.36,326/- with a deduction of Rs.4,326/- towards non-payable items with an assurance of refund of Rs.2000/- to the complainant which was by mistakenly  not deducted.

POINTS OF DETERMINATION:-

1. Whether the Complainant is comes under the purview of Consumer Protection Act.1986?
2. Whether the O.P has committed any Deficiency in Service to the Complainant?      

From the above discussion and materials available on record we inferred that the Complainant is a consumer of the O.Ps because he has an account in the bank of O.P-1, availed health insurance from O.P-2 & 4 by paying premium and undergone paid treatment from O.P-3. He made efforts to get cash less medical

facility from the Insurance Company by providing relevant documents but could not get proper response.  It was the case of the complainant that due to wrongful denial of the cashless facility by the Insurance Company, he suffered financially and was also subjected to physical and mental harassment. He therefore filed a complaint claiming reimbursement of medical expenses along with compensation.

Needless to say that the Hospital provided all necessary information to the Insurance Company to make available cash less facility to make to the complainant. But the Insurance, a made stoic Company silence for the reasons best known to it. Therefore by implication it amounted to denial of cash less facility which turn proves deficiency on the part of the Insurance Company. This matter has been well settled in the case of “Satya Prakash vs ICICI Lombard General Insurance” decided by Hon’ble State Consumer Disputes Redressal Commission, Delhi, on 5 March, 2014. Again the O.P-2 has not refunded an amount of Rs.2,000/- which was received from the Complainant at the time of his registration in the Hospital of the O.P-3 which shows the oblique intension towards Consumers as the O.P-3 ought to have informed about this to O.P-2 while settlement of the Insurance claim. As the non-payable items are deductible as per the guidelines of the Insurance Company, so the O.p-2 & 4 has rightly denied to compensate the same. In the fact and circumstances, the Opp. Parties No-2,3&4 have committed “Deficiency in Service” u/s-2(1)(o)    are  liable to pay compensation as per the order as follows:-

                                                                                                  ORDER

Petition is allowed. The O.P-3 is directed to refund Rs.2,000/- to the Complainant along with @ 9% interest per annum from the date of discharge i.e. dtd. 02.09.2017, which was received as an advance from the complainant/Patient at the time of registration in to the Hospital of O.P-3. Again Opp. Parties No-2,3,&4 are jointly and severally  directed to pay Rs.20,000/- (Rupees Twenty Thousand)as compensation and Rs.5,000/- (Rupees Five Thousand) towards the cost of litigation expenses within 30 (Thirty) days of receiving of this order, failing which, the complainant is at liberty to proceed in due process of law.       

            Order pronounced in the open court today i.e., on 7^th day of August,2018 under my hand and seal of this forum.

Office is directed to supply free copies of the Order to the parties free of costs receiving acknowledgement   of the delivery thereof.

 

I agree,                                             I agree,                                            

 

MEMBER.(W)                                 MEMBER.                                        PRESIDENT.

                                                Dictated and Corrected

                                                                By me.

 

                                                            PRESIDENT.