Orissa

Cuttak

CC/20/2021

Bajarang Lal Sharma - Complainant(s)

Versus

The Oriental Insurance Co Ltd - Opp.Party(s)

self

09 May 2022

ORDER

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

                                                                                C.C.No.20/2021

           Sri Bajrang Lal Sharma,

S/O:Late Kanheya Lal Sharma,

Res. Of Plot No.1C/67,Sector-9,CDA,

P.O/P.S:Markat Nagar,Dist:Cuttack-753014.                     ... Complainant.

 

                                                Vrs.

M/s. The Oriental Insurance Co. Ltd.,

Citi Division Office-I,

Lewis Road,Bhubaneswar.                                                      ... Opp. Party.

 

Present:               Sri Debashis Nayak,President.

                                Sri Sibananda Mohanty,Member.

 

Date of filing  :  04.02.2021

Date of Order:  09.05.2022

 

For the complainant:    Self.

For the O.Ps:                   None.

Sri Sibananda Mohanty,Member         

            The case record is put up today for orders.

            The complainant has filed the present case as the O.P repudiated his claim for   health check-up being not admissible as per policy conditions.  The case of the complainant is that he had taken a Health Insurance Policy under PNB-Oriental Royal Mediclaim policy during the year 2013-14 through Punjab National Bank(CDA branch) being an account holder of Punjab National Bank.  The said policy was being renewed till date without any disruption.  The complainant had incurred expenses of Rs.4330/- towards Health check-up of himself and his spouse-Draupadi Sharma.  He then claimed such expenses from the  O.P. as per clause-8 of the prospectus which reads as under:-

Cost of Health Check:  The insured i.e. the PNB Account holder/Employee only and not his/her family members shall be entitled for reimbursement of cost of Health check up undertaken once at the expiry of a block of every four continuous claim free underwriting years provided there are no claims reported during the block.  The cost so reimbursable shall not exceed the amount equal to 1% of the average basic sum insured during the block of four claim free underwriting years. IMPORTANT: Health Check-up provision is applicable only in respect of continuous insurance without break.

  Hence, the complainant on 22.7.2019 as per clause of prospectus claimed Rs.2000/-  instead of Rs.4,330/-for reimbursement of medical expenses he had incurred for himself.  The O.P repudiated the claim as it relates to health check-up, which is not permissible under policy terms and conditions. So the complainant approached the insurance Ombudsman at Bhubaneswar, who awarded Rs.2000/- in his favour on 16.6.2020.  In spite of this award, the O.P did not pay the claim amount as awarded by the Insurance Ombudsman.  Hence the complainant vide his letter dt.30.7.2020 reminded the O.P to honour the award passed by the Insurance Ombudsman.  It is also alleged that the clause-8 of the brochure denying reimbursement of cost towards health check-up of his spouse is bad as the scheme covers the account holder of PNB including his/her eligible family members, and family member includes his spouse as per the definition of family as mentioned in the salient features of the policy prospectus under 1.1a(b).   The rule framed by the Insurance Company in this respect is detrimental to the interest of public and in particular to the insured.  Hence he has filed the case for a direction to O.P to reimburse Rs.4330/- which he had  incurred on himself and his spouse towards Health-check-up, so also prayed for direction for payment of Rs.10,000/- towards compensation for mental agony and harassment and Rs.2000/- towards litigation expenses.  The complainant has filed the copy of documents and present policy in support of his case.

2.         The O.P in spite of notice, did not prefer to appear, hence he has been set exparte vide order dt.4.5.2022.

3.         Keeping in mind the contentions of the complaint petition, this Commission feels it proper to settle the following issues:

            i.          Whether the case as filed is maintainable?

            ii.         Whether there is any cause of action to file the present case?

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

Issue No.1.

            The complainant had taken his health insurance policy under PNB/Oriental Royal Mediclaim Policy by giving premium amount.  Hence he is a consumer under the O.P and the case is maintainable.

Issues No.2 & 3.

            Issues No.2 & 3 are taken up together for the sake of convenience.  The O.P has neither appeared not filed his version.  Hence the averments made in complaint petition are presumed to be true.  The clause-8 of prospectus issued by O.P in relation to PNB- Oriental Royal Mediclaim policy reads as follows: 

Cost of Health Check: The insured i.e. the PNB Account holder/Employee only and not his/her family members shall be entitled for reimbursement of cost of Health check up undertaken once at the expiry of a block of every four continuous claim free underwriting years provided there are no claims reported during the block.  The cost so reimbursable shall not exceed the amount equal to 1% of the average basic sum insured during the block of four claim free underwriting years. IMPORTANT: Health Check-up provision is applicable only in respect of continuous insurance without break, his spouse is not entitled to reimburse the medical check-up expenses.

The clause-8 of prospectus of O.P reveals that the complainant is entitled for Health Check-up expenses.  But the O.P since 12.4.2019 are not settling the claim.  The O.P also is very adamant as because he is not honouring the award passed by Insurance Ombudsman.  Hence it is a clear case of deficiency of service by O.P and the complainant has cause of action to file this case.  But he is entitled to Rs.2000/- towards health check-up expenses incurred by him as per clause-8 of prospectus as stated above.  Hence, it is ordered;                                                                         ORDER

            The case is allowed partly against the O.P exparte. The O.P is hereby directed to settle the claim of the complainant to the tune of Rs.2000/- towards health check-up expenses with interest @ 12% per annum from 22.7.2019 till the final payment is made to the complainant.  The O.P is further directed to pay a sum of Rs.5000/- to the complainant towards mental agony and harassment caused to him together with litigation cost of Rs.1000/-.  This order is to be carried out within a month hence.

Order pronounced in the open court on the 9^th day of May,2022 under the seal and signature of this Commission.

                                                                                                                                                                                                       

                                                                                                                            

                                                                                                                         Sri Sibananda Mohanty

                                                                                                                            Member.

 

                                                                                                                            Sri Debasish Nayak

                                                                                                                                        President