Orissa

Rayagada

CC/348/2016

Mrs. Sulata Pradhan - Complainant(s)

Versus

The Manager in Charge Birla Sul Life Insurance - Opp.Party(s)

Self

09 Oct 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

                                      PO/DIST; RAYAGADA,   STATE:  ODISHA ,Pin No. 765001

C.C. Case  No.    348/ 2016.                                     Date.       09     10   . 2018.

P R E S E N T .

Dr. Aswini  Kumar Mohapatra,                                                   President

Sri GadadharaSahu,                                                                        Member.

Smt.Padmalaya  Mishra,.                                                              Member

 

Mrs. Sulata Pradhan, W/O: Mr. Rama Chandra Pradhan, Po/Vill: Jammuguda of Tikri, Dist:    Rayagada, State:  Odisha.                                                                                                                                                                                                                                                                                                …….Complainant

Vrs.

1.The   Manager-In-Charge, Birla Sun Life Insurance, Kapil Towers, C-wing, Dr. Ambedkar Road, Sangam Bridge, Pune- 4110012.

 2.The  Manager-In-Charge, The MD India (Regional Office), Door No. 103, Ist. Floor, 6-4-884/A/1, Imperial Plazaw, Panjagutta, Near Topaz Building, Hyderabad-82.                                                                                                                           .…..Opp.Parties

Counsel for the parties:                                 

For the complainant: - Dr.  N.Kishore Kumar Patnaik, Advocate, Berhampur.

For the O.Ps  :- Sri Jitendra Kumar Mohapatra, Advocate, Rayagada.

                                                          J u d g e m e n t.

          The  present disputes arises out of the complaint petition filed by the above named complainant alleging deficiency in service  against  afore mentioned O.Ps for non reimbursement  of balance medical expenses towards medi claim  towards  policy No. 005614042.

Upon  Notice, the O.Ps put in their appearance and filed  written version through their learned counsel in which  they refuting allegation made against them.  The above O.Ps  taking one and another pleas in the written version   sought to dismiss the complaint as it is not maintainable  under the C.P. Act, 1986. The facts which are not specifically admitted may be treated  as denial of the O.Ps. Hence the O.Ps prays the forum to dismiss the case against  them  to meet the ends of justice.

The O.Ps appeared and filed their written version.  Heard arguments from the  learned counsel for  the  O.Ps  and from the complainant.    Perused the record, documents, written version  filed by the parties. 

The  parties advanced arguments inter alia  vehemently opposed the complaint touching the points both on the facts  as well as on  law.

                                                         FINDINGS.

On the basis of the pleadings of the parties, the sole question of determination is  Whether  the complainant is entitled  to insurance claim made by him ?

On perusal of the record this forum observed  there is no dispute that life assured  had  taken a whole life insurance plan (BSLI) vision   Insurance plan policy   bearing No. 005614042  for a yearly premium  of  Rs. 19,999.55   which  was issued on  Dt. 12.06.2012 (Copies of the policy is in the file which is marked as Annexure-I). The complainant had renewed the said policy thrice.  The complainant  was  suffered  from ailment in spiral problem for which  she    was   admitted  on 27.05.2015 at Appollo Hospital, Hyderabad and was  discharged on  01.06.2015 for treatment of Discectomy.   The complainant spend total Rs. 3,00,000/- and submitted  her claim along with  required documents  to the O.Ps  for reimbursement of above amount (copies of the medical bill is in the file which is marked as Annexure-2). Due to non reimbursement of the above amount  by the O.Ps  the  complainant  filed this C.C. case  before this forum.

The O.Ps in their written version contended that the present complaint is false, frivolous,  vexatious and abuse of the process of this  forum and therefore, the same is liable to the dismissed Under Section -26 of the C.P. Act.  The O.Ps further contended that  the present complaint does not raise any “Consumer Dispute” as defined under the Section  2(e) the C.P. Act, and therefore the same is liable to be dismissed. Again  forum has no jurisdiction  to entertain the present complaint. There is no  deficiency  of service or negligence on the part of the O.P. No.1. It is stated “Deficiency” is defined under section-2(g) of the C.P. Act, 1986 which means any fault,  imperfection, shortcoming or inadequacy in the quality,  nature and manner of performance, which is required to be maintained  in pursuance of the contract.  In the present case, the complainant has failed to establish  any   deficiency  in instant matter. Thus, the present complaint is liable to be dismissed on this count alone. The O.P. No.1 has renewed the said policy thrice. Thereafter the O.P. No.1 has received a claim for Hospitalization of the complainant  that the complainant  for treatment of Discectomy   on  Dt. 8.6.2015  towards the said policy.   Thereafter  the O.P  No. 1  on receipt of the aforesaid  claim documents reviewed the same and that in order to evaluate  the claim  further  the O.P. No.1 requested the complainant  vide letter Dt. 7.9.2016 to submit requisite  documents for further evaluation.  Further the  complainant  sent a legal notice  Dtd. 17.8.2016 which was replied back on Dt. 9.9.2016 reiterating to   submit   requisite documents called for vide letter    Dt.7.9.2016 to evaluate the claim further(copies of the letter Dt. 7.9.2016 and Dt. 9.9.2016 are annexed herewith  and marked as  Annexure-3 & 4 ). Again the O.P. No.1 has appointed  a third party Administrator (TPA) approved by the IRDA as a health service provider.  At the time of  health  claim  the policy owner needs to contract the TPA for intimation  and claim settlement and all claim related  documents are to be sent to the TPA. The contact details of the TPA are pvovided in the welcome letter attached to the policy  documents.  In the  instant case the TPA is MD India Care Services (TPA) Pvt. Ltd. Every  details are mentioned in the policy document, however the complainant has deliberately avoided to read the policy document.

The O.Ps  in their written version contended that  the complainant has availed the Hospital care  Rider in the subject policy for which she agreed to pay annual rider premium of Rs.713.98. The sum assured taken under this policy for Hospital care benefit is Rs.1,50,000/-. There is clearly stipulated under the clause of Hospital care benefit in the BSLI Hospital care rider provision, the calculation of the daily cash benefit  which is mentioned below.

Hospital care rider :- Calculation- 0.4% of  Rs. 1,50,000/- (Sum insured) = Rs.600  x 5 (No. of days in Hospital). Therefore   as the complainant was admitted for 5 days in Apollo Hospitals, Hyderabad from Dt. 27.5.2015 to 1.6.2015, she was entitled to   be paid   Rs.3,000/- as per the hospital care rider provision availed under the policy.  Screen shot of the rider sheet is in the file  which is marked as Annexure-5.  The terms and conditions of the said policy is clearly mentioned here under:-

Hospital Care Benefit.

The benefit amount  is payable for each hospitalization of the life insured for a peiod of at least 48 hours.  The hospitlisation must occur while this rider is in effect and the total benefit amount shall  be the sum of

1. Daily  Cash Benefits.

Benefits amount shall be 0.4% ( or 1/250^th) of the rider sum assured for each day of hospitalization starting from the date of admission to the hospital.

The O.P No.1 communicated vide letter Dtd. 25.10.2016  to the complainant  as per terms and conditions has settled the matter for Rs.3,000/- on account of Rider plan and the claim amount has been credited in the account of the complainant’s account (84020892626)  through NEFT Ref No. 161028AF3GN00003 on Dt.28.10.2016( Copies  of the letter Dt. 25.10.2016 is in the file which is marked as  Annexure-6).

On perusal of the record this forum found the O.P. No.1 had issued policy bearing No. 005614042 on Dt. 12.6.2012 in the name of the complainant. Thereafter the O.P. No.1 has renewed the said policy thrice.  Thereafter  the O.P. No. 1 had received a claim for Hospitalization of the complainant for treatment of Discetomy. . The  O.P. No.1 had communicated vide letter Dtd. 25.10.2016 to the complainant   that the O.P. No.1 as per terms and conditions has settled the matter for Rs.3,000/- on account of Rider benefit provision availed under the policy and the claim amount has been ciredited in account of the complainant’s account.  This forum found  the O.P. No.1 as per the terms and conditions   has settled the matter for Rs.3,000/- on account of Rider Benefit provision availed under the plan. The complainant never approached the O.P. No.1 with the grievances of receiving  the less amount.

The O.P. No. 1 relied citation  in the  case  of Suraj Mal Ram Niws Oil Mills (P )Ltd  Vrs. United India Insurance Co. Ltd   reported  in  (2010) 10 SCC 567  where in the apex court  observed   “that the   terms of the policy  are in the nature of a contract and their interpretation has to be   made in accordance with the strict  construction of the contract. Thus, the words in an insurance   contract must be given paramount importance   and interpreted as expressed without any addition, deletion or substitution”.

The O.P. No.1 in their written version  contended that  the complainant had not approached the O.P. No.1  with her grievance that she has received less claim amount under the policy  rider benefit which substantiate the fact that the complainant  is trying to make malafide gains in the said policy issued by the O.P. No.1 .

On perusal of the documents it is revealed that despite several adjournments taken  by the complainant for the purpose of filing relevant papers, the complainant failed to produce any documents in support of her claim.  When material  facts  pleaded by the complainant in support of his claim have been denied by the  O.P. the complainant is duty bound   to substantiate his claim by producing relevant documents there for, but she has failed to do so.  On the basis of mere pleadings of the complainant, which is no evidence, no positive finding can be recorded in regard to his claim. Hence, we are constrained to hold that the petition made by the complainant vis-à-vis  non satisfaction of his insurance claim is  devoid of any merit.

In  view  of  our above observation, finding, evidence on record it is concluded that the  complainant miserably  failed to establish his claim before the forum  and hence  the petition is dismissed against the O.Ps.  

Therefore   the   complainant   would  not be  entitled  to benefit under  the  said  policy.

 

Thus,  it    becomes clear that even on merits, complainant is  not entitled to  any claim.

                                               

                                                            ORDER.

 

In resultant  the petition filed by the complainant stands disposed of with no order as to cost and compensation.

            Serve the copies of above order to the parties free of cost.

            However  the O.P. No.1 is directed  to  reimburse   the balance medical bill  amount  if any  pending  for further settled  as   claimed by the complainant be take initiation to settle  the claim of the  complainant     as per policy  terms and conditions.  The complainant is   directed  to make correspondence with  the O.P No.1 for his claim if not satisfied with the  payment made  earlier  by the O.Ps  for  reimbursement  of balance medical bills the complainant have to  submit  all the bills  received from the Apollo  Hospital before the O.P. No.1 along  with  required documents for quick  settlement  of the  claim as demanded by the O.P. No.1.

Dictated and corrected by me.   

Pronounced on this        09^th.   Day  of  October,   2018.

 

 Member.                                            Member.                                             President