Shri A.K.Patra,President:

1. The captioned consumer complaint is filed by the complainant named above inter alia alleging deficiency in service & unfair trade practice on the part of the Ops for denial of cash-less treatment and for delayed in settlement of claim & for release of less claimed amount there under a health insurance policy.
2. The complainant seeks for the following reliefs:- (i) Hold the Ops liable for unfair trade practice and deficiency in rendering service to the complainant,(ii) Direct the Ops to pay the balance amount i.e. Rs.1,62,001/- towards surgery cost to the complainant, (iii) direct the Ops to pay Rs.50,000/- as consolidated amount towards travel cost, food cost, attendant cost etc. to the complainant, (iv) direct the Ops to pay Rs.1,00,000/- towards cost of mental harassment to the complainant,(v) direct the Ops to pay Rs.50,000/- towards an exemplary cost, (vi)direct the Ops to pay Rs.30,000/- towards cost of litigation and advocate fees,(vii) pass any other relief/reliefs as this Hon’ble Commission may deems fit & proper in the interest of justice, equity and good conscience.
3. The factual matrix leading to the case of the complainant as emerged from the case record is that, on dt.30.03.2013 the complainant opted Health Insurance Policy from the Ops vide Policy No.573764433 being entrapped by the exciting offer & benefit shown by the agent of the Op insurance company and since then he has been renewing the policy till date by paying renewal premium amount of Rs.4,069/- every year. At the time of obtaining the aforesaid policy, the OP 2 asked the complainant for his medical report and it was clear from his medical report that, the complainant was not suffering from any serious disease at any point of time and he put his signature on the policy paper as marked by the agent and paid the premium of Rs.4069/- . During April, 2018 the complainant suddenly felt pain in his chest and had a heart attack. He immediately rushed to “Metro Heart Institute” at Faridabad which is a well known institute for cardiac science for his check up. On dt.25.04.2018 the complainant admitted at” Metro Heart Institute” and on the same day he had to undergo with heart surgery. Before his surgery he called to the office of OP 2 and informed them about his surgery and requested for cashless treatment but surprisingly they turned down his request stating that, there is no “cash less policy “ he shall get the benefit of reimbursement after submission of bills and vouchers. Somehow, the complainant arranged cash from his local friends with much difficulties and undergone with heart surgery and spent Rs.1,75,001/-  towards hospitalization cost with extra travelling cost, attendant cost, food and lodging cost etc. At the time of taking policy, the agent of LIC assured for   complete cashless treatment during the policy period. After returning to his home, the complainant submitted all his documents including all the hospitalization documents in original, travelling expenses, food and lodging expenses etc. to initiate his claim at the office of OP 2 where his claim was unprocessed for around six months for the reason best known to him. Thereafter, the complainant received a letter from the OP1 for submission of additional documents and accordingly the complainant complied with the letter and furnished all the necessary documents required for settlement of claim but still his claim could not be processed for the reason best known to them.  After one year the Ops closed his claim by transferring him 13,000/-only whereas hospitalization cost itself was more than Rs.1,75,001/- which caused frustration of the very purpose of the insurance and suffered mental agony .Hence, this complaint. 
4. To substantiate his claim the complainant has filed the following documents (i) copy of latest renewal premium receipt, (ii) copy of bill for his heart surgery at “Metro Heart Institute”,  (iii) copy of bill settlement receipt, (iv) Relevant Investigation Report, (v) 5 Nos. Pathological
   Test (vi) Discharge Summary,(vii) Percutaneous Coronary Intervention Report, (viii) 7 Nos. documents received under RTI from the Office of OP 1.
5. Being notice the Ops appeared through their Learned Counsel Shri S.K.Panda and filed their written version inter alia denying the petition allegation on all its material particulars.
6. It is submitted by the Ops that,  the complainant has procured Jeevan Arogya (Plan No.903) bearing Policy No.573764433 through the  agent Hanif Khan  and in the said policy there  is no such provisions of Cash less hospitalization cost and all other expenses borne by him. The complainant being an educated person has opted for the policy paying yearly premium of Rs.4069/- . In this policy there is provision of Initial “Daily Benefit” of Rs.2,000/- and it is a fixed reimbursement plan for treatment, irrespective of the treatment costs involved. The Opposite Party has never asked for any medical report from the complainant and basing on his statements and answers in the proposal form by the proposer in utmost good faith and with a declaration that the statements are true and complete in all respect with the signature of the complainant on it and paid the premium. The Opposite Party knew about the treatment of the complainant at Metro Heart Institute during the period 24.04.2018 to 27.04.2018 through the complainant only
7. and it is reiterated that, the policy Jeevan Arogya (Plan No.903) is a fixed benefit reimbursement plan for treatment, irrespective of the treatment costs involved. The complainant has to spend money as required for his treatment knowing that the policy he has taken does not cover “cash-less” facilities.
8. It is further submitted by the Ops that, the complainant has submitted claim forms to OP 1 and the claim of the complainant was processed as per procedure and some additional requirements has been called for vide letter dt.29.12.2018 as per the advice of the TPA and after requirements were completed by the complainant on 25.02.2019, the claim has been processed and settled as per provisions and entitlements of this policy and paid Rs.13,000/- which has been credited to the Bank account of the complainant by NEFT process on 26.03.2019. In this case the complainant is eligible for one day of applicable “Daily Benefit” in non ICU rate of Rs.2,600/- per day and two days of other  surgical benefits at the rate of Rs.5,200/- per day, thus total comes Rs.13,000/-  and the same is paid to the complainant and the claim of the complainant has been settled as per procedure and entitlements as such there is no deficiency of service on the part of the opposite party.
9. 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.
10. The complainant led his evidence on affidavit and proved his contention. The facts stated in his affidavit evidence are corroborating with the averments of the complainant petition remain un-rebutted.
11. The  Op 1 & 2 lead no evidence affidavit as prescribed under C. P. Act 2019.
12. Heard. Peruse the material on record. We have our thoughtful consideration to the submission of rival parties.
13. After perusal of the complaint petition, written version and all the documents relied on by both the parties placed in the record, the points for consideration before this Commission are :- (i) Whether the complainant is the consumer of the Ops ? (ii) Whether there is any deficient service & unfair trade practice played on the part of Ops causing  injuries to the complainant?   (iii) And whether the complainants are entitling for the relief(s) claimed?
14. Here in this case it remain un disputed that, the complainant was insured with OPs/the LIC of India  under   Health Insurance Policy  vide Policy No. 573764433 paying the yearly premium of Rs.4069/- and that, during the period of policy the complainant/insured   undergo with heart surgery but avail no cashless treatment facility.. The claim of the complainant is settled at Rs 13.000/-only against claim amount of 1,75,000/-and  disallowed the rest claim amount for the reason that, those are not admissible under the terms & conditions of the policy and claim of rest amount is repudiated vide letter dt. 26/04/2019 on the ground that claims does not cover under the said JEEVAN AROGYA Health insurance Policy ( Plan no.903).
15. At the cost of reputation letter vide letter dt. 26/04/2019 claim made on dt.19/06/2018 under subject insurance policy reimbursement of hospitalization cost during the period of 25/04/2018 to 27/04/2018 the OP/Insurer  stated that ;-“ Please note that, the benefit under the policy are not directly related to the actual expenses incurred by you. The benefit are calculated based on the Initial Daily  Benefit opted by you in the proposal forms, on the life referred above and the period of hospitalization and type of surgery eligible as per the policy terms and conditions as elaborated in the “Condition & privileges” referred to the policy documents .  The claim has been admitted as per Terms & Condition of the policy ,for the following benefit :_ (1) Health Cash benefit in NICU:-Rs.2000/- (2) Other Surgery benefit Rs.10400/- .The claim amount as shown above is being directly credited through NEFT to your Bank Account provided in NEFT mandate Form submitted by principal insured “
16. To substantiate their claim the Ops have filed the following documents (i) Scanned copy of proposal form of insured,  (ii) Scanned copy of Policy No. 573764433 ,   (iii)  Kit of Jeevan Aragya policy. It is seen that, the Kit of Jeevan Aragya policy contended attractive insurance benefits such as :-“*Cover extended family :Self +Spouse +Kids +Parents +in-law,*Hospital Cash Benefit,,*Major Surgical Benefit :-for 140  listed surgeries,*Day Care Procedure Benefit:- for 140 more listed surgeries,*other surgical Benefits :- for all other surgeries procedures ,*Full Entitlement paid irrespective of actual expenses,*50% Advance MSB available under Quick Case Facility .* No Claim Benefit/Increase health Cover,*Term/Accident rider for principal insured and spouse”. The Op has admitted the facts that, the complainant has procured subject Jeevan Arogya (Plan No.903) bearing Policy No.573764433 through the  agent Hanif Khan.  As such the contention of the complainant that, on dt.30.03.2013 the complainant opt the subject Health Insurance Policy from the Ops vides Policy No.573764433 being entrapped by the exciting offer & benefit shown by the agent of the Op which is affirmed by the complainant there in his affidavit evidence  cannot be disbelief.
17. The only last page of the Scanned copy of proposal form of insured of 4(four) pages content the signature of the principal Insured Pradeep Jain and the first three pages does not contained any signature of the Principal Insured so also it does not contained the signature of the agent of the Op as such it is not reliable to accept as evidence against the complainant to hold that said Proposal Form is made by the complainant/principal insured under the subject policy. So also the Ops have failed to filed evidence affidavit as prescribed under the C.P.Act 2019 to proved their contention & documents as such we are unable to hold that, the insured has chosen for “Initial Daily Cash Benefit:-Rs.2000/-“only and have not chosen all other attractive benefit there reflected in the aforesaid Kit of “Jeevan Aragya” policy placed on the record by the Ops. Rather it is proved on affidavit of the complainant that , during purchasing of the subject policy it was falsely convinced that:-” if any health issue arises during the active policy period, the policy holder shall get cash less hospitalization cost and all other expenses born by him” remain un-rebutted.
18. Here in this case, no scrap of paper contending any term & condition or exclusion clauses is placed on record. Law is well settle that, onus lies on the insurer to prove that the claim fall under exclusion clauses of the insurance policy but failed, so also the insurer has failed to produce any evidence to established that, the term & condition of the policy has ever been communicated to the insured as such in absence of any cogent evidence it cannot be concluded that, the treatment & surgery undergone by the insured fall under any exclusion clauses of the subject insurance policy. It is found that, the insurer has derailed from its promised is clear instance of Unfair Trade Practice as defined U/S 2(47)(f) of C.P Act 2019 which runs as follow:-“makes a false or misleading representation concerning the need for ,or the usefulness of ,any goods or services;”. As such we are of our opinion that, complainant is entitle for insurance benefit under the alleged policy and it is not proper to settled the insurance claim @ Rs.13,000/- against the claim of Rs 1,75,000/- though  said expenditure accrued for treatment of the complainant /insured is not disputed by the op /insurer in any manner .
19. The Ops have not placed on record any documents whatsoever to establish that, there is certain term & condition of the policy for admissibility & deduction of any amount accrued by the insured during treatment as such we are of the opinion that, the deduction made against the claim of the complainant is not proper.
20. During hearing of this case the Ld.Counsel for the complainant submitted that, all required documents have been sent to the insurer for settlement of the claim but the insurance company has time & again asked to submit same document only to harass the complainant and tried to avoid their liability under the policy.  On perusal of the documents available on the record we found much weight on the submission of the complainant.
21. Putting the insured in harassment by not providing cash less treatment and asking for submission of documents time & again as per the sweet will of the insurer is nothing but unfair contract as defined u/s 2(46)(vi) of C.P.Act,2019 which may be quoted here :-  “imposing on the consumer any unreasonable charge, obligation or condition which puts such consumer to disadvantage” is certainly went against the interest of the consumer is  not  permissible under C.P.Act . Here the O.Ps have falsely represents that, they will provide cash less medical treatment as insurance benefit under subject  Health Insurance Policy during hospitalization of the complainant but Op 1 & 2 have admittedly failed to provide cash less treatment during critical situation of the insured /complainant  & tried   to escape from their  liability is certainly an act of Unfair Trade Practice as such the interest of the consumer is to be protected in the sprite of C.P Act 2019 and the OP/insurance company should be discourage from repetition of same acts of unfair trade practice with any other bonafide insured person as such we think it proper to impose exemplary cost upon the Ops of not less than Rs.25,000/-(twenty five  thousand)  payable to the Consumer Welfare Fund of the State of Odisha so that, the OP/Insurance company shall not repeat the   same act of unfair trade practice.
22. The complainant has prayed to award Rs. Rs.50,000/- as consolidated amount towards travel cost, food cost, attendant cost etc. but no cogent evidence is placed to proved that he has accrued such expenditure during treatment as such said claim is not admissible . Rather, on perusal of the undisputed medical papers & bill  placed on the record it is found that, the complainant has incurred  Rs.1,75,000/- for his treatment  under gone while insurance policy was in force   but the insurance company has settled the claim at Rs 13,000/-only .It is further found that, required documents for settlement of the claim has already been submitted to the insurer and copies thereof are available in the case record as such we are of the opinion that ,the Insurance company is  liable to release deducted amount of Rs. 1,62,000/ with interest @ 9% P.A from the date of discharge i.e.  from 27/04/2018 to its realization to the complainant  as we have already hold that , the deduction made against the claim of the complainant is not proper.
23. In view of the discussion stated above we are of the opinion that, the complainant is the consumer of the Ops by purchasing insurance policy of the OPs .The  OPs denied  cash less treatment to the complainant at the peril during insurance period and delayed in settlement of claim of the complainant/insured by asking production of same documents time & again and that ,there is arbitral deduction from  actual expenses of treatment is  certainly  a deficient service and unfair trade practice on the part of the Ops/Insurer which caused financial hardship & mental agony to the complainant   cannot be denied  as such there is sufficient cause of action against the Ops to present this complaint. The cause of action for this complainant arose on 26/04/2019 when the OP has arbitrarily settled the claim of the complainant @ Rs. 13,000/- only by denying rest of the claim and this complaint is present on dt. 16/10/2019 before this Commission within the jurisdiction of which the complainant is reside as such the complaint is found to be in time, well maintainable under C.P.Act,2019 before this commission for adjudication.  In absence of cogent evidence the preliminary objection raised by the Ops that, complaint is not maintainable before this commission under C.P Act is here by rejected.
24. Based on the above discussion this complaint is allowed in part against the OPs on contest with the following directions:-                                              

ORDER

1. The Ops /LIC of India  is here by  directed to release the rest claimed amount of  Rs. 1,62,000/- with interest @ 9% P.A from the date of i.e.  from 27/04/ 2018  to its realization to the complainant  as insurance benefit under the subject insurance policy and,
2. Further directed to pay Rs.25,000/-(twenty five thousand ) as compensation  to  the complainant towards financial hardship & mental agony suffered which include litigation expenses of this complaint .
3. It is further directed to comply the order within 45 days of receiving of the copy of this order, failing which Ops shall personally pay Rs 200/-each per day  as delayed compensation to the complainant till its realization.
4. The consumer complaint is partly allowed in above term. Pending application if any is also stands disposed of accordingly.

Dictated and corrected by me.

              Sd/-

          President         

I   agree.

       Sd/-                         

 Mebmber

Pronounced in open Commission today on this 29^th day of November 2023, under the seal and signature of this Commission. The pending application if any is also disposed off accordingly.

This complaint could not be decided within the prescribed period of time due to COVID -19 situations & in want of quorum of this Commission.

      Free copy of this order be supplied to the parties for their perusal or party may download the same from the Confonet be treated as copy served to the parties. Complaint is disposed of accordingly.