Orissa

Cuttak

CC/140/2022

Birendra Kumar Behera - Complainant(s)

Versus

The Manager Claims(HI),LIC of India - Opp.Party(s)

A K Bose & associated

20 Oct 2023

ORDER

IN THE COURT OF THE DIST. CONSUMER DISPUTES REDRESSAL COMMISSION,CUTTACK.

C.C.No.140/2022

 

           Birendra Kumar Behera,

           S/o:Late Bhramarbar Behera,

           At:Plot No.D/603,Sector-6,CDA,

           P.S:Markag Nagar,Cuttack,

            Odisha-753014.                                                                 ... Complainant.

 

          Vrs.

 

  1.       The Manager Claims (HI),

Life Insurance Corporation of India,

Health Insurance Department,

Divisional Office(Jeevan Prakash),

P.Box No.-36,Cuttack-753001.

 

  1.      Health India Insurance TPA Services Pvt. Ltd.,

At:Neelkanth Corporate Park,

                   4th Floor,Korol  Road,Vidya Vihar Society

Vidya Vihar West,Mumbai-400086.                                 ....Opp. Parties.

 

 

Present:         Sri Debasish Nayak,President.

                      Sri Sibananda Mohanty,Member.

 

Date of filing:   14.07.2022

Date of Order:  20.10.2023

 

For the complainant       :          Mr. A.K.Bose,Adv. & Associates.

For the O.P. No.1             :          Mr. R.K.Pattnaik,Adv. & Associates.

For the O.P No.2             :                          None.

 

Sri Debasish Nayak,President       

Case of the complainant as made out from the complaint petition in short is that on 10.2.2021 the wife of the complainant had fallen down from the scooter at about 7.30 P.M in Sector-8,CDA area of Cuttack while crossing an unmarked speed breaker.  The wife of the complainant thereafter was shifted to Shrusti Hospital where she was admitted and treated and ultimately on 13.2.2021 morning she was discharged from the said hospital.  The final medical bill at the hospital was of Rs.77,305/- which was paid by the complainant.  The complainant has a Mediclaim policy bearing No.597852956 for an assured amount of Rs.5,00,000/-.  The complainant has urged through his complaint petition that since because he had entered into the policy agreement with OP no1, legally the O.P is liable to pay the amount as per the contract.  On 26.7.2021, the complainant had submitted his application to the O.P in the prescribed format alongwith all necessary documents. The complainant had received a letter on 7.9.2021 wherein certain queries were made by O.P no.2 asking the details of the FIR if submitted.  The complainant had replied through his letter dated 15.9.2021 that no FIR was lodged for the said accident.  The complainant had approached this Commission when the O.Ps refused to pay any claim as made by him and has prayed to direct the O.P no.1 in order to pay him the medical expenses as incurred by him to the tune of Rs.87,305/- towards treatment of his wife alongwith interest thereon @ 15% per annum from the date of hospitalisation till the total amount is quantified and also to pass any other order as deemed fit and proper.

          Together with his complaint petition, the complainant has filed copies of some documents in order to prove his case.

2.       Out of the two O.Ps as arrayed in this case, having not preferred to contest this case, O.P no.2 has been set exparte vide order dt.6.10.2022.  As such, O.P no.1 has only contested this case and has filed his written version wherein it is averred by O.P no.1 that the case of the complainant is not maintainable and the complainant has no cause of action for filing this case since because the claim of the complainant has not yet been repudiated. Rather, it is pending due to want of documents from the complainant.  It is admitted by the O.P no.1 that the complainant had obtained health insurance policy bearing no.597852956 wherein his wife is a beneficiary.    It is not disputed by the O.P no.1 that during subsistence of the said policy, the wife of the complainant had met with an accident on 10.2.2021 at Sector-8,CDA area of Cuttack as because she slipped from the scooter and was thus admitted to Shrusti Hospital on that day.   She was treated there upto 13.2.2021 and the complainant had made his claim before the O.P no.1 on 26.7.2021 for a sum of Rs.87,305/-.  The O.P had written to the complainant asking for the copy of FIR, MLC, self-statement regarding injuries/trauma and cost of the injuries in order to process the claim which the complainant had received on 7.9.2021.  After getting the said letter, the complainant had remained silent for which the O.P was constrained to issue another reminder to the complainant on 30.11.2021.  Still the complainant remained silent for which a mail was sent to him on 24.2.2022 to that effect.  That inspite of cooperating with the O.Ps, the complainant has filed this case hastily without providing the required documents in order to process the Mediclaim as initiated by him.  It is for this, the O.P no.1 through his written version has prayed for dismissal of the complaint petition as filed by the complainant.

          Together with his written version, the O.P no.1 has also filed copies of certain documents in order to support his stand.

3.       Keeping in mind the averments as made in the complaint petition and the contents of the written version of the O.P no.1, this Commission thinks it proper to settle the following issues in order to arrive at a definite conclusion here in this case.

i.          Whether the case of the complainant is maintainable?

ii.         Whether there was any deficiency in service on the part of the O.Ps  ?

iii.        Whether the complainant is entitled to the reliefs as claimed by him?

Issues no.1 & ii.

Out of the three issues, issue no.i & ii  being the pertinent issues are taken up  first for consideration here in this case.

After going through the complaint petition, the written version of O.P no.1, the written notes of submissions from either sides and also after perusing the copies of documents as available in the case record, it is noticed that undoubtedly, the complainant had availed health insurance policy bearing no. 597852956 from the O.Ps.  It is not in dispute that on 10.2.2021 the wife of the complainant had slipped off from the scooter at Sector-8,CDA area of Cuttack for which she was admitted to Shrusti Hospital and was treated there upto 13.2.2021.  It is also admitted that wife of the complainant was under the coverage of the health insurance policy as obtained by the complainant and during the subsistence of the said policy, this accident had occurred.  After getting the claim application from the complainant, O.P no.1 sought for certain documents in order to process the claim of the complainant.  As per the requirement of the O.Ps, the complainant is required to file the copy of FIR, MLC and self-statement regarding the cause of injuries.  As it appears from the averments of the complaint petition, the complainant had written vide Annexure-4 that no FIR was lodged before any police station.  The complainant should have cooperated with the O.Ps by providing the copy of Medico Legal Case as obtained from the hospital authorities alongwith the self-statement declaration as regards to the cause of the accident.  But without providing those, as it is noticed here in this case, the complainant had hastily rather prematurely filed this case and specifically when the O.Ps have not repudiated the claim of the complainant which according to them, is still pending for want of documents.  Thus, this Commission arrives at a conclusion that the case of the complainant cannot be termed to be maintainable here and there is also no deficiency noticed on the part of either of the O.Ps.  Accordingly, issues no.i & ii goes in favour of the O.Ps.

Issue No. iii.

From the discussions as made above, the complainant is not entitled to the reliefs as claimed by him.  Hence it is so ordered;

                                              ORDER

Case is dismissed on contest against the O.Ps and as regards to the facts and circumstances of the case without any cost.

Order pronounced in the open court on the 20th day of October,2023 under the seal and signature of this Commission.                                                                                                                

                                                                      Sri Debasish Nayak

                                                                                  President

                                                                             Sri Sibananda Mohanty

                                                                                      Member

 

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