DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KEONJHAR

                                    CONSUMER COMPLAINT CASE NO 8 of 2022

Sri Nihar Ranjan Mishra, aged about 46 years,

S/o- Late Harihar Mishra, Permanent resident of Village/Po- Palaspang,

P.S- Keonjhar Sadar, District- Keonjhar,  Odisha-758031

presently residing at village: Lane No-3 Baikuntha Bihar,

Telephone Bhawan Chhaka, P.O- Keonjhargarh, P.S-Keonjhar Town,

District- Keonjhar, Odisha-758001, Phone No- 9438191175

Dist- Keonjhar   …………………..…………………………………Complainant.

-Versus-

1.The Chief Manager, Star Health and Allied Insurance Company Limited,

   2^nd  Floor, Plot No-23(E), Ashok, Nagar, Bhubaneswar, Odisha-751009

2. The Manager Star Health and Allied Insurance Company limited,

    Regd. & Corporate Office 1 New Tank street, Valluvar Kottam High     

    Road, Nungambakkam, Chennai-600034

3. The Manager, Star Health and Allied Insurance Company limited,

    Branch office At- Jagannathpur Chhaka,

    In front of New Court building and beside of Bajaj Allianz Insurance Co Ltd,

    Po- Keonjhargarh, P.S-Keonjhar Town,

    Dist-Keonjhar 758001…………………………….………………… Opp. Parties

Present:

Sri B.N.Patra, President

Sri. J.K.Behera, Member I/C

Advocate for complainant- Self

Advocate for O.Ps  1 & 2, 3 – P.K.Pothal

Date of  filing -  02.02.2022                                                   Date of order - 24.02.2023

B.N Patra (President)

The facts of the case in nut shell is that on dt. 29.12.2020 due to severe stomach pain the complainant took advice of doctor at Indian Institute of Gastro Interology and Hepatology, Cuttack  for his treatment. Where after primary diagnosis doctor advised for surgical operation of gold bladder stone. For that complainant was admitted in Shakti Hospital, Cuttack. The complainant had a Family Health Optima Insurance Plan for cash less treatment. Complainant got contact with the agent where Ops’ company approved Rs 39,000/- which was paid to hospital directly. Apart from that the complainant has spent Rs 27,980/- for that operation. The complainant has approached the Ops’ Company for payment of the extra expenses. Company could not settle the extra claim, for such failure of dereliction of duty the complainant filed this case praying for Rs 27,480/- as extra expenditure amount and Rs 50,000/- for mental agony from Ops.

The complainant has relied for the following documents as follows-

1. Photocopy of insurance certificate

2. Photocopy of money receipt

3. Photocopy of cashless authorization letter

Under the above complaint the case is admitted and notice issued to OP No. 1,2 & 3  appeared and filed their written version. Learned advocate for the OPs submitted that the complainant has not come to the court in clean hands and suppressed the facts for which case is liable to by dismissed. The complainant did not approach the insurance company for reimbursement of medical expenses after his discharge on dt. 02.01.2021. Ops also submitted that the complainant has never submitted bills of Rs 56,000/-,  Rs 1820/- Rs 300/ Rs 800/-, Rs 1200/- The Op parties company relied upon the following documents.

1. Photocopy of policy schedule
2. Photocopy Policy terms
3. Photocopy Pre authorization form
4. Photocopy of Bill of Rs 39,000/-
5. Cashless approval letter dt. 30.12.2020 to 02.01.2021

Under the above situation it is necessary to attend the following issues to determine the case.

1. Whether the Ops have made any deficiency in service?

2. Whether the complainant is entitled to get any relief?

In this case there is no doubt that the complainant had a valid of health insurance policy Vide No-P/191200/01/2020/005633 with renewal endorsement No. P/19200/01/2021/00/639 of his family of sum assured Rs 5,00,000/-. For the Gall bladder operation of complainant the Op company has approved Rs 39,000/- but as per clear condition policy No. (H) & (I)that facility of pre hospitalization and post hospitalization is applicable.

The complainant claimed as per the bill and also seen from the bill of Shakti Hospital Cuttack total amount as Rs 56,000/- but company approved Rs 39,000/-. So it is clear that Op company intentionally avoided to pay the rest amount. So also the pre hospitalization and post hospitalization charges Rs 27,480/- which was not paid by the OP company. We hold to believe that the Op company have made infirmities to pay the insurance claim which  is  deficiency in  service and unfair trade practice.

Order

The Ops is directed to pay Rs 27,480 to complainant along with Rs 10,000/- as compensation for mental harassment within 15 days of receipt of this order.

It is further directed that if Ops failed to comply the order  they will pay 6% interest P.A on total amount of Rs 37,480/- from the date of this order till realization.

Pronounced the order in open Commission today i.e. on dt. 24.02.2023.

Free copy be supplied to parties, if applied for.

       I   agree 

 ( Sri J. K. Behera)                                                                                    ( B.N. Patra )

   Member,I/C                                                                                (President)

DCDRC, Keonjhar                                                                                          DCDRC, Keonjhar

Dictated & Corrected by me.

                                                                       ( B.N. Patra )                                                                                                                                                    (President)

                                                                    DCDRC, Keonjhar