Orissa

Sambalpur

CC/2/2016

Suresh Kumar Tibrewal - Complainant(s)

Versus

United India Insurance Co. Ltd. - Opp.Party(s)

S.K. Mahapatra

27 Jun 2022

ORDER

PRESIDENT, DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

Consumer Case No- 2/2016

Present-Dr. Ramakanta Satapathy, President,

  Sri. Sadananda Tripathy, Member,

 

Suresh Kumar Tibrewal

S/O- Sri. Motilal Tibrewal

R/O- Behind A.I.R.Colony, Sakhipara, Sambalpur

Ps-Dhanupali

Dist- Sambalpur-768001, Odisha.                                 ……..Complainant

Vrs.

1. United India Insurance Co. Ltd.,

At-Gaity Road, Sambalpur, Ps-Town

Po/Dist-Sambalpur        .

2. M/S Vidal Health TPA(P) Ltd.

At/Anmol Plani, No.88, G.N. Chetty Road,

L 2, T.Nagar, Chennai-600017.

3. M/S Branch Manager, Indian Bank

L.T. Road, Po/Dist-Sambalpur-768001                         ….….Opp. Parties

Counsels:-

1. For the Complainant       :-         Sri. B.K.Mahapatra, Advocate & Associates.
2. For the O.P.1                    :-         Sri. G.C.Panda, Advocate & Associates.
3. For the O.P. 2 & 3           :-          Ex-parte

DATE OF HEARING : 20.04.2022, DATE OF JUDGEMENT : 27.06.2022

   Dr. Ramakanta Satapathy, PRESIDENT:

1. The Complainant took a Health Policy bearing No. 010500/2014/48410000140/3 in continuation of old policy for the period 10.7.2014 to 30.6.2015 paying premium of Rs. 6146.00 to the O.P No.1 . The policy issued covering the risk of the Complainant, his wife Santosh Devi and his son Saurav Tibrewal.

                   The Complainant affected by cataract and admitted in Healing Touches Hospital and Nursing Home on 27.12.2014.for operation of his eyes and discharged on 28.12.2014 by Dr. D.N Bhuyan, Professor KIMS Medical College. An amount of Rs.18000/- was spent for operation and Rs.640/-for pathological tests.

                   The Complainant informed the O.P No.2, third party administrator (TPA) who collect insurance policies and settle the claims for O.PNo.1. The Complainant submitted claim form and submitted the requisites through mail and speed post . The O.P No.3 was also informed, who is the collecting agent of the policies. 

                   The Complainant when not received any response from O.P No.2 made a personal visit to Chennai on 24.2.2015, who advised to submit the IOL sticker in original for settlement of claim. It was complied on the spot. The O.P No.2 sent SMS regarding receipt of all documents on 24.2.2015.

                   When the O.Ps not settled the claim E-Mail was made on 23.3.2015, reminder on 30.3.2015 and ultimately a notice through E-Mail on 15.4.2015 made to O.P No.2 with hard copy to O.P No.3. No any action was taken by the O.Ps for which this complaint was filed.

2.     The Contesting O.P No.1 Insurance Company after appearance submitted its written statement stated that the O.P-2 is an insurance regulator has been nominated by O.P No.1 to act as third party arbitrator for processing and settlement of claim of Health policy of O.P No.1. The O.P No.2 is only liable for payment .under the policy in case of any hospitalisation/operation of insured only, when the same is done in any hospital/nursing home, which has registration number issued by Competent authority and having qualified nursing staff round the clock. The company shall also not liable for any payment under this policy in respect of insured person for treatment of any pre- existing condition, until 48 months of continuous coverage of such insured person, policy has elapsed since inception of first policy with the company. The Complainant never informed the O.P No. 2 about cataract suffering.

          The O.P No.2 has never advised pathological test like FBS, Creatinine, lipid profiles, Urea etc. Claim form Part ”A” was incomplete, in no letter head of Hospital/Nursing Home with registration number, PAN etc of the nursing home it was signed . The operation was un-authorised. On 14.1.2015 the Complainant was informed about 6.2.2015 and 24.2.2015 queries raised by O.P No.2 and finally on 24.2.2015 only cancelled cheque for ECS was submitted by the complainant . The Complainant not met the queries. The Complainant not made the grievance directly to the O.P No.1, the claim is not proper and sort for dismissal of the complaint.

          After receipt of notice the O.Ps 2 &3 have not taken any step for filing of written version and they have been set ex-parte as per order dated 12.09.2016.

3. After perusal of the complaint, version of the O.P No-1 and document filed by the parties, the following issues are framed.

I S S U E S

1. Whether the Complainant submitted the claim form for the mediclaim policy and required documents before the O.P No.2(Third Party Administrator) and the O.P No.2 informed the Complainant that the file is closed?
2. Is there any deficiency on the part of the O.Ps regarding settlement of claim?
3. What relief the Complainant is entitled to get?

Issue No.1 Whether the Complainant submitted the claim form for the mediclaim policy and required documents before the O.P No.2(Third Party Administrator) and the O.P No.2 informed the Complainant that the file is closed?

          It is the admitted case of the Complainant and the contesting O.P No.1 that the complainant has obtained a health policy from O.P No.1 through O.P No3 having policy No. 010500/2014/48410000140/3 and the policy was valid for 10.7.2014 to 30.6.2015. The Complainant has paid insurance premium of Rs. 6146/- to the O.P. No.1 through O.P No.3. The O.P No1 is the insurer, the O.P No.2 is the marketing agent and settles and the O.P No. 3 is the agent of the policy. The plan is “Indian Bank Arogya Rakhya Plan”. Neither the Complainant nor the O.Ps have filed any policy terms Conditions, exclusions and definition. The O.P No.1 while issuing certificate of the policy mentioned that a copy can be obtained from Indian Bank Branch. The proposal and the declaration by the insured is the basis of this contract and deemed to be incorporated”.

          It is the general tendency of business houses, they obtain unilateral documents and do not provide copy to the customer. In the instant case also the  same situation are seen. The O.P No1 has not submitted the proposal form, declaration made by the Complainant, conditions, exclusions and definitions part as mentioned in the certificate issued. Accordingly the stand of the O.P No.1 that the cataract operation undergone  by the Complainant from unauthorised centre, their registration number PAN number etc is not acceptable for medical treatment as it is emergent in nature, permission from the insured is not necessary. After undergoing operation the Complainant has submitted the claim form and documents in his hand. From the correspondences of the Complainant and O.P No.2 it reveals that the O.P No.2 (T.P.A) sort for certain queries. It was the duty of O.P No.2 to make a field survey, contact the concerned doctor whether the Complainant has submitted genuine documents or not..

          The Complainant was operated on 27.12.2014. The claim was filed through-Mail on 07.01.2015   after discharge from 28.12.2014. As per annexure 12(1) of the Complainant the O.P No.2 confirmed the receipt of required documents and vide mail dated 22.4.2015 acknowledged the receipt. On 28.4.2022 the O.P No.1 submitted certain documents which was not filed earlier after appearance in this case. The documents are:-

1. Letter of O.P No2 dated 7.6.2016 to the Complainant.
2. Report of one Fanny Ronald/CHN/UIIC addressed to Sushil Kumar Padhi/BHU/UIIC@UIIC, Pradip Kumar Nanda, when received the notice of this Commission in C.C Case No 02/2016. The Print out is made on 06.06.2016, where in it is shown that the file was closed on 29.08.2015.

          The O.P No.1 failed to file any document acknowledging the closure of the file, by Complainant. From this it is crystal clear that the O.P No.2 not made any correspondence regarding closure of the mediclaim files of the Complainant. It was done only after receipt of the notice of this Forum/Commission.

          Suppression of material facts in business term reflect the intention of party to a contract. The O.P No.2 by not disclosing policy terms and closure of mediclaim file, made the insurance contract unilateral. Accordingly the issue is answered against the O.Ps

Issue No 2 Is there any deficiency on the part of the O.Ps regarding settlement of claim?

          The O.P No.1 in its version stated about un-authorised source of operation of the Complainant, whereas not submitted the authorised hospital list. Further suppression of closure of mediclaim file of Complainant is not intimated to the Complainant, the terms of contract and condition clause filed by the O.P. No.1. From this Conclusion is drawn that the O.Ps are deficient in their service. Accordingly the issue is answered against the O.Ps.

Issue No.3 What relief the Complainant is entitled to get?

          From the discussion supra, it is clear that the Complainant entitled for relief claimed for. It is ordered:

ORDER

          The Complaint is allowed on contest against O.P. NO.1 and Ex-parte against O.P. No.2 & 3. The O.Ps are jointly and severally liable to pay Rs. 18,640 to-wards medical expenses, Rs.25,000/- to-wards compensation and harassment of the Complainant and Rs. 10,000/- to-wards litigation expenses. From the day of filing of complaint, it will carry 4% P.A. interest. In case the O.Ps failed to pay the amount within one month, the amount will carry 12% interest P.A. till realisation.

          The O.P. No.1 made statement in its version without any supporting documents and its amounts to suppression of facts, which is an ‘unfair trade practice’.

Accordingly a Compensation of Rs. 50,000/- is imposed on the O.Ps. The amount will be deposited in Consumer Welfare Fund of the state within one month of this order.

Order pronounced in open court on his 27^th day of June 2022.

Supply free copies to the parties on proper application.