The Complainant:-Shri Mukesh Ranjan Jena,Advocate

The OP No.1 & 4 : Not appeared

The Opposite Parties2 & 3 : Shri S.K.Panda & P.N.Panda ,Advocate.

                                                            JUDGEMENT

Shri A.K.Patra,President:

1.     This captioned consumer Complaint is filed  by the complainant named above alleging   negligence and deficiency in service  for less settlement of claim of  insurance benefit under Policy No.34601/48/2019/168 i.e. Happy Family Floater 2015  purchased  from  the Oriental Insurance Company Ltd.
2.     Complainant has prayed for an order directing the O.Ps to reimburse Rs.93174/- which was not allowed by the Ops under the said insurance policy and to release Rs.3428/- i.e. the cost of medicines taken after operation and further pray for an award of compensation of Rs.50,000/- towards mental agony and humiliation suffered by the complainant and his wife due to deficiency in service on the part of  the Op and to award litigation cost of Rs.10,000/- to the complainant.
3.    Heard .Perused the material available on record. We have our thoughtful consideration on the contention of the both parties.
4.    Brief fact of the complaint is that, on being pursued by the B.M, Oriental Insurance Company Ltd. Bhawanipatna, the complainant has purchased an insurance policy vide No.346001/48/2019/168 i.e. Happy Family Floater 2015 of the OP for the period of 19.11.2018 to 18.11.2019 paying adequate premium of Rs.10727/- covering his family member of five persons and sum insured amount being two lakhs . The policy is intended to indemnify medical claim of his wife Babita to the tune of Rs.3,00,000/- only, for complainant Rs.3,00,000/- and three of his wards for Rs.1,00,000/- each. It further submitted that, on 19.08.2019 the wife of the complainant under gone treatment in Apollo Hospital Bhubaneswar . Surgery through complex high risk TLH Laparoscopic and got discharged on 23.08.2019 from the  Apollo Hospital .The  Health Insurance Policy issued by the OP was in force at the time of admission for which the Apollo Hospital  promised cash less transaction on the basis of the insurance policy. Total bill raised to the tune of Rs.1,61,362/- but only Rs.68,188/- was allowed  under the said insurance policy and the complainant was compelled to pay the rest amount of Rs.93,174/- to the hospital authority which frustrated the very purpose of the purchasing of said insurance policy. The insurance policy also intends to cover the post operation medical expenses of the insured/wife for which a letter dt.26.08.2019 was written to the Op to settle  the rest of her claim i.e. Rs.93,174/- (which was not allowed by the hospital authority) and medicine expenses  for post surgery period i.e. Rs.3428/-  in total Rs.96,602/- is within the coverage of the insurance policy but OP could not respond to released it. Hence this complaint.
5.    To substantiate his claim the complainant has filed the photo copy of the following documents:- (i)  copy  the Policy No.34600/148/2019/168 of Happy family floater 2015,(ii) letter dt.22.07.2019 addressed to B.M, Oriental Insurance Co. Ltd,(iii) Discharge summary of Apollo Hospital Bhubaneswar-4 sheets(iv) The entire  bills of Apollo Hospital(12 sheets) (v) Payment of Rs.93,174/- through Credit Card by the HDFC,(vi)Letter of wife of the complainant to the op dt.26.08.2019.
6.     On being notice, OP appeared through their leaned counsel Sri.S.K.Panda  and  filed their written version denying the petition allegation on all its material particulars. However health insurance coverage under the alleged insurance policy is not disputed. It is averred that, insurance company/OP has never promised to consider the entire claim of the complainant rather the claim of the complainant is settled by the TPA M/s Vidal Health Insurance Pvt. Ltd. as per policy condition. The Policy being silver plan the TPA settled the claim amount at Rs.68, 188/- after considering all aspect of the policy. It is further submitted that, the OP has never issued any policy to the complainant to indemnify medical claim of wife of the complainant to the tune of Rs.3,00,000/- rather the amount shown in the policy is towards PA coverage and not medical coverage. The OP never perused the complainant to take the insurance policy covering five number of his family rather, the complainant being an educated person having basic knowledge of health insurance had taken the policy voluntarily paying regular premium in order to keep his policy active. It is not within the knowledge of OP that, the wife of the complainant detected with Fibroid in the Uterus . It is further submitted that, the hospital has raised bill according to the facilities and medical expenses incurred by the complainant’s wife and that,the claim of the complainant is settled by the TPA M/s Vidal Health Insurance Pvt. Ltd as  per the term of the policy who is not made a party in this case for which this case is bad for non joinder for necessary party. There is no cause of action arose to file this complaint, nothing deficient in providing service to the complainant on the part of the Ops. With this submission the OP urged to dismiss the complaint against the OP with cost.
7.     To substantiate their claim the OP has filed the summary of the claim settlement of the complainant along with copy of Happy Family Floater Policy 2015 which contains the term and condition of the policy.
8.     Both the parties have failed to adduced evidence affidavit as prescribed under Section 38 (6) of C.P.Act,2019.Complainant is remaining absent on the date fixed for hearing. However, case is taken up to decide on merit in view of Sec. 38(3)(c) of C.P.Act,2019.
9.     After perusal of complaint petition, written version of the OP and all the documents placed on record by both the parties, the only point for consideration before this Commission is whether there is any deficiency in service on the part of the Ops on settlement of the medi- claim of the compliant under the alleged insurance policy?
10. The Op has admitted the insurance policy and its was in force as on the date of treatment of the wife of the complainant is not disputed. The TPA M/s Vidal Health Insurance TPA   Pvt. Ltd, named in the insurance policy schedule placed by the complainant on the record, is   authorised to settle the claim is also not disputed. It is ascertain from the  documents vide Serial No.1 i.e. Insurance Policy Schedule annexed with the complaint petition that , the name of the TPA who entrusted to settle the claim of complainant under the insurance policy mentioned as such the complaint is well aware of the fact that, claim is to be settled by the said TPA and here in this case it is not disputed that the claim is settled by the said TPA.  But here in this case ,the said TPA M/s Vidal Health Insurance TPA   Pvt. Ltd. is not made a party who is a necessary party as such we are of the opinion that this case is bad for non joinder for necessary party.
11. As per Sec. 38(6) of C.P.Act,2019 every complaint shall be heard by the District Commission on the basis of affidavit and documentary evidence placed on record ; as such it casts an obligation on the District Commission to decide the complaint on the basis of evidence brought to its notice by the complainant and the service provider/seller, irrespective of whether the service provider/seller adduced evidence or not. The decision of the District Commission has to be based on evidence relied upon by the complainant. The onus thus is on the complainant making allegation.
12. Law is well settled that mere pleading is not evidence. (held in Rabindra Nath vrs M/S Karnani Praperty Ltd ,CAN23/11 ,Honourable High Court Kolkota).
13. No evidence on affidavit as prescribed in C.P. Act 2019 is adduced by the complainant. The photo copy of documents filed by the complainant along with his complainant petition without authenticated by fundamental evidence that, the photo copy is in fact a true copy of the original may not be accepted as evidence,(Reliance placed on the ratio of judgement of Honourable Supreme Court in M.Chandra Vrs. M. Thangamuthu & another ,reported in 2010(ii) CLR (SC) 746 :(2010) 9 SCC 712 ) .Further it is held in Paramananda Sahu Vrs. Babu Sahu& others reported in 36(1970) CLT 1211 that, without taking any step for production of original or laying the foundation for secondary evidence production of copy of itself is not admissible in evidence . Here the  complainant has failed to adduce any cogent evidence  to substantiate his claim.
14. Law is well settled that, complainant is to prove deficiency in service as alleged against the Ops but here the complainant failed to prove any negligence & deficiency of service on the part of the Ops.
15. Based on above facts & circumstances and settled principle of law, we are of the opinion that this complaint sans merits. Hence, complaint is dismissed against the OPs on contest. However, no order as to cost.
16. Pending application if any is also stands disposed off accordingly.

  Dictated and corrected by me.

President

I   agree.

Member    

 Pronounced  in the open Commission today on this   12^th day of April 2023 under the seal and signature of this Commission. Pending application if any is also stands disposed off accordingly.

The judgment be uploaded forthwith in the website of the Commission. Free copy of this order be supplied to the respective parties or they may download the same from the Confonet  to treat the same as copy of the order received from this Commission.