Orissa

Sambalpur

CC/73/2016

Tiluram Agrawal - Complainant(s)

Versus

The Managing Director (Universal Sompo General Insurance Co. Ltd.) - Opp.Party(s)

Sri S.S. Panda

20 Jul 2022

ORDER

PRESIDENT, DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

Consumer Case No-73/2016

Present-Dr. Ramakanta Satapathy, President,

  Sri. Sadananda Tripathy, Member,

Tiluram Agrawal,

S/O-Banwarilal Agrawal

R/O-Renuka Bangles Store , Golebazar

PO-Sambalpur, PS-Town

Dist- Sambalpur, Odisha.                                                        …..Complainant

 

Vrs.

1. The Managing Director, Universal Sompo General Insurance Co. Ltd.

At-Express IT Park, Plot No. EL-94, TTC Industrial Area,

MIDC, Mahape, Navi Mumbai-4000710

2. Managing Director, Universal Sompo General Insurance Co. Ltd.

Gurgaon Corporate Office, Plot No. 577,

Udyog Vihar, Phase-5

Udyog Vihar-122016 (Haryana).

3. The Branch Manager, Allahabad Bank,

At/Po-Golebazar, Ps-Town,

•  

Counsels:-

1. For the Complainant      :-Sri. S.S.Panda Advocate & Associates.
2. For the O.P.1 & 2            :- Sri. B.K.Purohit, Advocate & Associates.
3. For the O.P.3                   :-None

 

DATE OF HEARING : xxxxxx, DATE OF JUDGEMENT :20.07.2022

Presented by Dr. Ramakanta Satapathy, PRESIDENT.

1. The case of the Complainant is that the O.P. No.3 is the agent and being influenced the Complainant took a health case plus policy on 21.09.2015 from O.P. No.1. The Policy No. is 2827/54447120/000. The Complainant paid premium of Rs. 2671/- for the period 26.09.2015 to 25.09.2016 covering Rs. 100,00,00/-.

During October 2015 the Complainant was admitted in Astha Nurshing Home, Sambalpur on 05.10.2015 under treatment of Dr. Rajib Acharya, Stayed as an indoor patient from 05.10.2015 to 10.10.2015, paid a sum of Rs. 12,063/- to-wards the final bill of nursing home, medicines and pathological tests. Towards cost of attendants and nutrious diet the complainant claimed Rs. 12,065/- earlier.

After recovery on 04.11.2015 the Complainant registered claim No. 100111502578. The O.Ps vide letter dated 16.01.2016 asked to submit documents. Although the Complainant hospitalized due to U.T.I. infection, the O.Ps insisted to submit documents relating to diabetic treatments. The bed head ticket are not available to the patients but demanded the same. The O.Ps were requested to verify the same from the nurshing home. The O.Ps did not consider the claim and kept it pending. The O.Ps are deficient in their service and accordingly the Complainant sort relief before this Forum/Commission.

2. The O.P. No.1 & 2 after appearance filed their version and submitted that the O.P. No.1 & 2 issued policy No. 2827/54447120/01/000 to the Complainant for the period 26.09.2015 to 25.09.2016 MN, policy namely Allahabad Bank Health care plus policy. E-Meditek TPA Service Ltd. is the Agent to provide services for health insurance policy.

Claim No. 100111502578 for Rs. 12,063/- was claimed by the Complainant for his health problem like fever and UTI stricture Urethra. The Claim was redirected to third party arbitrator (TPA) E-Meditek TPA services ltd. The TPA requested for submission of documents and to provide information to the O.Ps. The insurer failed to provide the speaking letter of repudiation dated 09.02.2016 the Complainant was informed.

Allahbad Bank is not an agent of O.P. No.1 & 2 but an intermediary. The Complainant claimed Rs. 12,226/- with the enclosures of some prescriptions, diagnostic report and the discharge document. The documents required by the TPA were to draw a conclusion affirmatively or negatively for settlement of claim.

The Complainant in his claim bifurcated the claims which is Rs. 5000/- to-wards room rent, Rs.620/- to-wards investigation Rs. 2443/- to-wards medicines Rs. 3500/- towards surgeon fees, Rs. 163/- for consumable and Rs. 500/- consultation fees. The O.Ps had no option to request for indoor papers but the Complainant not submitted.

Non settlement of Claim is not deliberate. The Complainant is not entitled for any claim as the O.Ps are not deficient in their service.

3. Perused the documents filed by the parties. The Complainant has paid Rs. 2619/- premium for health insurance under policy No. 2827/54447120/01/000vide collection No. 1015410150 dated 21.09.2015. The Complainant was admitted in Astha Nurshing Home as an indoor patient from 05.10.2015 to 10.10.2015 for treatment of U.T.I. stricture Urethra. The treatment was during the period of insurance coverage.

In this case the Complaint has not made party to the TPA and made the O.P. No.3 wrongly. In the policy the O.P.S have mentioned in a small box. What is the role of TPA has not been mentioned. For a consumer it is difficult to ascertain the same and its role for which the Complainant has not made party to the T.P.A.

It is the admission of O.Ps that they received claim and documents from the Complainant and sort for further documents for clarification to come to an affirmative or negative conclusion. Bed head ticket has not been submitted by the Complainant. When no bed head ticket was provided it was the duty of the O.Ps to come to the treating Nurshing Home and ascertain the facts and documents. This part of the O.P. No.1 & 2 lacking in this case.

On 27.05.2016 a pleader notice has been sent to the O.Ps by the Complainant and when no any action was taken filed the complaint on 13.09.2016. Annexure-2 the no claim letter filed by the O.Ps reflect the date 28.09.2016 which is after filing of the case. The O.Ps failed to file any acknowledgement of the Complainant. From this it is concluded that when the O.Ps got the notice of the Forum, hurriedly issued the ‘no claim notice’ for paper transaction only. The O.P. No.1 & 2 are deficient in their service and accordingly liable to pay the claim.

Now the quantum of claim is to be determined in this case as follows:

Towards final bill the Complainant has paid Rs. 9000/- on 10.10.2015 to Astha Nurshing Home, Sambalpur.

Date	Paid to	Amount
05.10.2015	Arogyan diagnostic	Rs. 500.00
07.10.2015	Arogyan diagnostic	Rs. 120.00
06.10.2015	Planet Medical Hall	Rs. 828.00
07.10.2015	Planet Medical Hall	Rs. 519.00
08.10.2022	Planet Medical Hall	Rs. 414.00
08.10.2022	Planet Medical Hall	Rs. 99.00
09.10.2022	Planet Medical Hall	Rs. 583.00
	Total	Rs. 3063.00

                  

                   In this a Grand total Rs. 12,063/- expenditure has been made by the Complainant to-wards treatment during the period. The Expenditure is covered under the policy head “What we cover”. The prayer of the Complainant is specific and entitled for the claim. Accordingly it is ordered:

ORDER

The Complaint is allowed on contest against the O.P. No.1 & 2. The O.P. No.1 & 2 are directed to pay Rs. 12,063/- with 12% interest w.e.f 04.11.2015 till the date of realisation. Further the O.P. No.1 & 2 are directed to pay compensation of Rs. 38,000/- and litigation expenses of Rs. 10,000/- within one month from the date of order, failing which the entire amount will carry 12% interest till the day of realisation. Order pronounced in open court on this 20^th day of July 2022.

Supply free copies to the parties.