DATE OF DISPOSAL: 27.06.2023

SRI SATISH KUMAR PANIGRAHI, PRESIDENT

The fact of the case in brief is that the complainant has filed this Consumer complaint under section 12 of the Consumer Protection Act, 1986 alleging unfair trade practice by the Opposite Parties (in short O.Ps) and for redressal of his grievance before this Commission.

2. The complainant is a beneficiary under the Medi claim policy, under the O.P. and the dependant of Senior journalist-cum-Sub-Divisional Reporter Aska of Oriya daily SARBASADHARANA, having its registered office at Bhubaneswar. For the welfare of the working journalist of Odisha State, the Department of Information and Public Relation Department, Govt. of Odisha being a policy under Health Insurance Scheme- 2016, under the Gazette Notification No. 11981/PC-36/16/IPR BBSR dated 29.11.2016 where it was notified that for the health insurance of the working journalist and their family members the insurer has to pay 25% and government has to pay 75% of the insurance premium for the total insured amount of Rs.2,00,000/-. Further to give utmost care and safety to the family of the working journalists of Odisha State the government has been further pleased to bring an amendment on the policy which was known as “Odisha State Working Journalist” Health Insurance Scheme Amendment Rule-2017 on 11.01.2018vide Notification No. PC36/16/548/IPR, Bhubaneswar wherein it was substituted in Rule-7, the clause (ii) as “Govt. shall pay 100% premium for insurance of Rs.2.00 lakh per year for the journalists to be covered under the policy.  After due amendment in the Gazette Notification on 11.01.2018, the father of the complainant accordingly made the application through I & PR Department of Govt. of Odisha to insure the family members of the working journalist under the Health Insurance Scheme 2016 on 22.01.2018. On receiving the application the O.P. has been pleased to issue mediclaim policy under the scheme in the name and style of Paramount Health for southern Zone Odisha state vide its EMP. ID: JSO701900, PHS ID- NI GAN 25226301 IPRD s valid from 01.06.2018 to 31.05.2019 under the policy Nos 550200/34/18/04/00000001, 550200/34/18/04/00000002 and 550200/34/18/01/00000003 under the account of I & PR Govt. of Odisha. To get the benefit of the medical treatment for the beneficiary AMARI Hospital Limited, Bhubaneswar is listed in the network provider. To the misfortune of the complainant, he was suffering from cardiac problem and admitted in AMARI Hospital, Bhubaneswar 27.04.2019 for recovery and due discharged from the hospital on 29.04.2019 from Male General Ward-3 after spending a total sum of Rs.1,97,081.88 from his own pocket. On admission of the complainant before the hospital, he has produced all the relevant health insurance documents and the mail was also send at 2.04 and 4.45PM on 27.04.2019 to the O.P. but no response was received by the hospital authority, for that the complainant incurred all the medical expenses. So on refusal of the hospital authority of cashless mediclaim, the complainant compelled to pay the demand amount with much financial hardship. The payment of billed amount is filed herewith. It is pertinent to mention here that though the complainant is a beneficiary under the mediclaim policy under the notification of Govt. of Odisha and he was duly enrolled for entitlement for the scheme, but the O.P. deliberately and intentionally harass the complainant and deviate them form in due discharges from their service. The O.P. has issued the Mediclaim policy after receiving the entire insurance premium amount from I & PR Department Govt. of Odisha and issued the Mediclaim policy in favour of the beneficiary, and deviate them from their service and remain silent by putting the beneficiary into unnecessary harassment. As there is no response from the O.P, the complainant has placed his grievance before the Secretary, Insurance Regulatory on 04.05.2019 but there is no respond from the side of the O.P. in this regard. But the O.P. without any compliance remained silent for months together and paid a deaf ear to the said intimation. After due acknowledgment of the intimation through the Secretary, Insurance Regulatory and Development Authority of India dated 04.05.2019 and due to willful default of the OP. in discharge of their service the complainant compelled to approach this Forum for its redressal. Alleging deficiency in service on the part of the O.P. the complainant prayed to direct the O.P. to pay the insured amount of Rs.1,97,081.88 paisa, Rs.1,00,000/- towards compensation and Rs.20,000/- litigation cost in the best interests of justice.

3. The Opposite Party filed written version through his advocate. It is stated that the O.P. had launched a policy namely as New India Flexi Floater Group Mediclaim policy to provide health insurance to the Employees/Members (including their eligible Family Members) subject to terms, conditions and limitation and has paid premium as consideration for such insurance. The Government of Odisha in order to provide health insurance to the working journalists of Odisha launched Health Insurance Scheme for which the Director of I & P.R. Department invited Quotation from different insurance organization. However this O.P. submitted their revised quotation to Health Insurance of Odisha State working journalist to the Director of I & PR Department of the Government of Odisha vide its letter No. BBSR-DOII/550200/SPP/01/2018 dated 26.04.2018. In the said revised quotation scope of the policy has been mentioned as follows: Family composition: (1+4), comprising of self+spouce+ 3 dependent children aged up to 25 years; per family sum insured on Floater basis: Rs.2.00 Lakhs; and period: 12 months from the commencement of policy. Without going through the scope of the policy and eligible family members, the working journalist furnished their name along with their list of family members to the Govt. for issuance of necessary health card. Whatever the list received from journalist, the Govt. without verifying eligible family members of the respective working journalist as per the scope of the policy simply forwarded the same to the TPA for issuance of Health card. The TPA without verifying eligibility issued Health ID card as per the list submitted by the Govt. When this O.P. came to know about such mistake, immediately blocked in the system those who are not deserve to gets benefit under the above health policy including the name of the complainant.  In the present case the father of the complainant was working journalist. The complainant was his major son whose age was more than 48 years by then and is working under Govt. of Odisha. As per the scope of the policy excluding working journalists, his spouse & 3 dependent children aged up to 25 years are eligible to get benefit under the above policy. The complainant is not eligible to get benefit under the above policy. He is neither a dependant nor his age was under 25 years. He is a Govt. Employee. The complainant cannot take advantage by getting health ID card wrongly issued in his favour. As the complainant is not coming under the scope of the above health policy, this O.P. repudiated his claim.  This O.P. has not committed any mistake to deal with the claim of the complainant. The O.P. as per the scope of the above policy has rightly repudiated the claim of the complainant. The State Government is a necessary party. The present case is not maintainable under the law. Hence the O.P. prayed to dismiss the case with exemplary cost.  

        4. On the date of hearing of the case, we heard learned counsel for the advocate for complainant and O.P and perused the case record and the materials placed on it. For the welfare of the working journalist of Odisha State, the Department of Information and Public Relation Department, Govt. of Odisha being a policy under Health Insurance Scheme- 2016, under the Gazette Notification No. 11981/PC-36/16/IPR BBSR dated 29.11.2016 where it was notified that for the health insurance of the working journalist and their family members the insurer has to pay 25% and government has to pay 75% of the insurance premium for the total insured amount of Rs.2,00,000/-. Further to give utmost care and safety to the family of the working journalists of Odisha State the government has been further pleased to bring an amendment on the policy which was known as “Odisha State Working Journalist” Health Insurance Scheme Amendment Rule-2017 on 11.01.2018vide Notification No. PC36/16/548/IPR, Bhubaneswar wherein it was substituted in Rule-7, the clause (ii) as “Govt. shall pay 100% premium for insurance of Rs.2.00 lakh per year for the journalists to be covered under the policy.  After due amendment in the Gazette Notification on 11.01.2018, the father of the complainant accordingly made the application through I & PR Department of Govt. of Odisha to insure the family members of the working journalist under the Health Insurance Scheme 2016 on 22.01.2018.  To get the benefit of the medical treatment for the beneficiary AMARI Hospital Limited, Bhubaneswar is listed in the network provider. To the misfortune of the complainant, he was suffering from cardiac problem and admitted in AMARI Hospital, Bhubaneswar 27.04.2019 for recovery and due discharged from the hospital on 29.04.2019 from Male General Ward-3 after spending a total sum of Rs.1,97,081.88 from his own pocket. On admission of the complainant before the hospital, he has produced all the relevant health insurance documents and the mail was also send at 2.04 and 4.45PM on 27.04.2019 to the O.P. but no response was received by the hospital authority, for that the complainant incurred all the medical expenses. So on refusal of the hospital authority of cashless mediclaim, the complainant compelled to pay the demand amount with much financial hardship.

            In the present case the father of the complainant was working journalist. The complainant was his major son whose age was more than 48 years on the date of treatment and is working under Govt. of Odisha. As per the scope of the policy excluding working journalists, his spouse & 3 dependent children aged up to 25 years are eligible to get benefit under the above policy. The complainant is not eligible to get benefit under the above policy. He is neither a dependant nor his age was under 25 years. He is a Govt. Employee. The complainant cannot take advantage by getting health ID card wrongly issued in his favour. There is no privity of contract between the parties as the complainant not paid any premium amount to the opposite party. In the present case, the I & P R Department, Govt. of Odisha has deposited the premium but the said department being necessary party has not been impleaded in the present case by the Complainant. The law is well settled in Kasturi v. Iyyamperumal and Others reported in (2005) 6 SCC 733 that, no effective decree can be passed in the absence of a necessary party. Hence, in our considered view there is no deficiency in service on the part of the O.P.

In the result we dismissed the case. No order as to cost and compensation. 

The Judgment be uploaded on the www.confonet.nic.in for the perusal of the parties.

A certified copy of this Judgment be provided to all the parties free of cost as mandated by the Consumer Protection Act, 1986 or they may download same from the www.confonet.nic.in to treat the same as if copy of the order received from this Commission.

The file is to be consigned to the record room along with a copy of this Judgment.

Pronounced on 27.06.2023