Orissa

Rayagada

CC/56/2016

Sri Pratap Kumar Mishra - Complainant(s)

Versus

The Manager, Reliance Life Insurance Co. Ltd, - Opp.Party(s)

Self

19 Feb 2018

ORDER

DISTRICT   CONSUMER  DISPUTES REDRESSAL    FORUM, RAYAGADA,

STATE:  ODISHA.

C.C. Case  No. 56 / 2016.                                Date.      19  .2. 2018.

P R E S E N T .

Dr. Aswini  Kumar Mohapatra,                   President

Sri GadadharaSahu, .                               Member.

Smt.  Padmalaya  Mishra,                          Member

Sri Pratap Kumar Mishra & Mrs. Sujatha Mishra,At: Block office lane, Po:Padmapur,       Dist.Rayagada,State:  Odisha.                                                …….Complainant

Vrs.

1.The Manager, Reliance Life Insurance Co. Ltd.,  Regd. No. 121, Regd. Office, H.Block, Ist. Floor, Dhirubhai Ambani knowledge City,  Navi Mumbai, State:Maharashtra- 400 710.

2. The Manager, M/S. Medi Assistant  TPA Pvt. Ltd., Team Reliance Wealth + health Srikrishna Arcade, #47$1, 9^th. Cross  Ist. Main road, Sarakki Indl. Lay  out  3^rd stage. J.P.Nagar, Bangalore-560-078.                                                                                      .…..Opp.Parties

Counsel for the parties:                         

For the complainant: - Self..

For the O.Ps :- Set  exparte.

                                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 payment  a sum of  Rs.60,779/- towards medi claim. The   brief facts of the case are summaried here under.

       1.That the complainant had opted health insurance policy during the year 2009 vide policy No. 14605740  for an annual premium Rs.10,000/-. The O.P. No.2 was the Agent of the O.P. No.1 for marketing the said product  and as  per their version the complainant had opted for the policy and the O.P. No.2 had undertaken  to give the help in case of health need and any correspondence regarding the claim  is to  be  processed through the O.P. No.2.  On Dt. 5.3.215 the complainant’s wife Sujata Mishra also covered under the policy admitted  into the AASTHA Hospital, Berhampur for Ventral Hernia, Herniotomy 1   Prolene Mesh  repair by Dr. Saroj Kumar Satapathy and hospitalized for  10 days from  5.3.2015 till  14.3.2015.  During the course of treatment the complainant had obtained all the  medical  bills and  prescription etc and submitted to the O.P.No.2  for process and submission for reimbursement to the O.P. No.1 as per the policy condition.  The  amount claimed as per the  actual bills was Rs. 60,779/- and the same was submitted  to the Branch Manager, Customer service centre of the O.P. No.1 at Rayagada and he had accepted the same along with all the relevant papers.   The amount claimed  is neither reimbursed by the O.ps nor rejected and kept it pending with them demanding a document i.e. (1) letter from the consultant stating details of previous surgery with duration   but such instance  have never come and they have  intimated the said fact to the O.Ps but till date the O.Ps have not reimbursed the  above amount. Hence this case. The complainant prays the forum direct the O.Ps  to pay the claim amount a sum of Rs.60,779/-as per the claim made on Dt. 28.4.2015 and such other relief as the hon’ble forum deems fit and proper for the best interest of justice.

On being noticed the O.Ps. appeared through their learned counsel Sri Ram Prasad Patra and took  adjournments.  Then the O.Ps neither entering in to appear before the forum nor filed their  written version inspite of more than  18 adjournments has been given  to them. Complainant consequently filed his memo and prayer to set exparte of the O.Ps.  Observing lapses of around 2 years  for which the objectives  of the legislature of the C.P. Act going to be destroyed to the prejudice of the interest of the complainant.  Hence after hearing  the  counsel for the complainant set the case  exparte against the O.Ps. The action of the O.Ps is against the principles of  natural justice as envisaged  under section  13(2) (b)(ii) of the Act. Hence the O.P. set exparte  as the statutory period  for filing of  written version was over to close the case with in the time frame permitted by the C.P. Act.

 

Heard learned counsel for the complainant.  Perused the  record  filed by the parties.

                                               

Findings.

During the exparte  hearing the complainant examined himself and proved the payment  of the  money  to the Medical store, and  diagnostic Research centre, Berhampur  which is marked as Annexure-I  to Annexure-IV.  The complainant also filed policy bond i.e. Reliance Wealth + health plan (Regular) which is marked as Annexure-5.  The complainant  also filed all the prescriptions, Testing  reports and corresponding letters between the parties relating to the operation made by the Doctor.   The complainant also argued  due to non reimbursement  of the above money he  suffered a lot of financial trouble  and mental agony. The complainant prays the forum as the  O.Ps have   not heard any  grievance of the complainant till date   so the  O.Ps  be  directed to reimburse the  amount a sum of Rs.60,779/- as   the complainants wife  Mrs. Sujata Mishra  undergone treatment  for open surgery  operation  of  Venral  Hernia  at AASTHA Hospital, Berhampur.

After carefully examining the evidence on record, we find no cogent reason  to disbelieve or discard the evidence already adduced by the complainant. The documentary evidence  tendered by the complainant clearly tends support and absolute corroboration   to  the evidence.  

In absence of any rebuttal materials from the side  of   O.Ps  there is no reason to disbelieve the evidence put forth  by the  complainant  before the forum  whose evidence  suffers from no infirmity. The evidence adduced by the complainant  clearly leads us to arrive at a just conclusion that there is not only deficiency  in service  but also negligence  on the part of the O.Ps  in not   reimbursing the amounts a sum of Rs. 60,779/-  to the complainant  towards medi claim   as per the  provisions laid down under section 14 of the  C.P. Act.

On careful analysis   of the evidence on record both oral and documentary, we are clearly of the opinion  that  inspite of doing the needful, the O.Ps are failed to redress the grievances of the complaint which amounts to  deficiency in service  as a result the complainant was constrained  to file this complaint before the forum claiming the relief as sought for.  In that view  of the matter the O.Ps  jointly and severally liable.

On perusal of the record  this forum found  the O.Ps  have continuously received the premium w.e.f. 2009 till today @ Rs.10,000/- per year  with the above  assurance but when the claim is placed for  such reimbursement towards Medi claim as per policy condition they  are avoiding  the same and as  such  it is a deficiency of service and they have never intended to extend  such benefit to the consumers and with false representation they are continuing  the policy  w.e.f 31.5.2009   to  31.5.  2024 and policy named  as  given Reliance wealth + Health plan (regular)  policy. While  the policy is in force  repudiation of Medi claim by the O.Ps  with out  any cogent reason  is an unfair trade practice and causing  financial hard ship and mental agony    to the complainant  and this policy  is only intended to collect the premium  and not to pay back the same at the event admitted/accepted  by the policy bond.

Not responding to the grievance of a genuine consumer amounts to deficiency in service and in that line we hold that all the parties  are jointly and severally liable.

            Hence to meet  the  ends  of  justice,  the following   order is  passed.

                                                            ORDER.

            In  resultant  the complaint petition is  hereby  allowed in part  on exparte against  the O.Ps

                The O.Ps   ordered to  reimburse the   amount a sum of Rs. 60,779/- towards Medi claim  inter alia Rs.5,000/- towards mental agony  and cost of litigation  to the complainant .                We therefore issued a “Cease and Desist” order against the O.Ps. directing  him to stop such a practice  forthwith and not to repeat in future. 

            The O.Ps are  ordered to comply the above direction within one month from the date of  receipt of this order. Service the copies of the order to the parties free of  cost.

Dictated and corrected by me

Pronounced on this               19th. day of   February, 2018.

 

MEMBER.                                MEMBER.                                                        PRESIDENT.