Date of filing:- 10/12/2018. Date of Order:-21/08/2023.
DISTRICT CONSUMER DISPUTE REDRESSAL COMMISSION,
B A R G A R H.
Consumer Complaint No. 71 of 2018.
Biswajit Panda, S/o. Late Bhagaban Chandra Panda, aged about 48 years, R/o. Nuasahi, Balia (Near City Clinic), Po. Kuruda, Dist. Baleswar 756056, presently R/o. House of Sita Panigrahi, Near Municipality Office, W.No. 10, Po/Dist. Bargarh (Odisha) Pin. 768028.
Complainant.
V e r s u s
- The Branch Manager, Life Insurance Corporation of India, Bargarh Branch Office, At. N.H. 6, Po/Ps/Dist. Bargarh 768028.
- The Divisional Manager, Life Insurance Corporation of India, Sambalpur Divisional Office, Jeevan Prakash, Post Box No.4, Ainthapali, Po/Dist. Sambalpur 768004
Opposite Parties.
Counsel for the Parties:-
For the Complainant :- :- Sri Pradeep Kumar Mahapatra, Advocate with Associates.
For the Opposite Parties :- :- Sri Kalpabata Sahu, Advocate.
-: P R E S E N T :-
Smt. Jigeesha Mishra ..... ..... ..... ..... ..... P r e s i d e n t.
Smt. Anju Agarwal ..... ..... ..... ..... ..... M e m b e r (W).
Dt.21/08/2023. -: J U D G E M E N T:-
Presented by Smt. Jigeesha Mishra, President :-
- The case of the Complainant is that the Complainant is a life insurance policy holder bearing Jeevan Arogya (Table 903) policy No. 594615551 issued by the branch of Opposite party No.1 from 06/11/2012 to 06/11/2050. The policy covers the risk of costs of medical expenses on account of illness of the life assured. During the subsistence of the policy the Complainant fell ill due to chest pain. He got himself admitted in the department of cardiology at Aditya Care Hospital, Bhubaneswar on 20/01/2018 for his treatment and discharged on 22/01/2018. For his treatment the Complainant had incurred medical expenses worth Rs. 26,631/-(Rupees twenty six thousand six hundred thirty one)only.
The Complainant lodged claim before the Opposite Party No.1 for indemnification of the medical expenses. The Opposite Party No.1 assured the Complainant to disburse the medical expenses as early as possible. The Complainant personally requested the officers of the Opposite Parties to look into the matter. But the Opposite Party did not care to settle the claim. On Dt. 03/09/2018 the Complainant served a notice through his advocate claiming settlement of the claim. The notice was duly received by the Opposite parties, but they remained silent. Non settlement of genuine insurance claim and non payment of genuine medical expenses of the Complainant for a long period amounts to deficiency in service and unfair trade practice on the part of the Opposite Parties. Hence the Complainant filed this case before this Commission.
- The case of the Opposite parties is that the Opposite parties filed their version. The Opposite Parties admitted that the Complainant is the Life insurance policy holder of Jeevan Arogya (Tab 903) bearing policy no. 594615551. The Opposite Parties submitted that the table Jeevan Arogya Covers the medical expenses, treatment and illness which is known as Hospital cash benefit. Under this policy the Opposite Party does not bear the cost of test, diagnosis and xray. The Opposite Parties submitted that on 26/11/2018 an amount of Rs. 5,200/-(Rupees five thousand two hundred)only is credited to the account of Biswajit Panda, the Complainant. Hence the Complainant is not entitled to further amount. The Opposite Parties are not deficient in their service and the Opposite Parties prayed for dismissal of the case.
- Perused the Complaint petition, version and documents filed by the parties and following issues are framed:-
-
1.Whether the Opposite Parties are deficient in their service ?
2. What relief the Complainant is entitled to get ?
Issue No.1.
It is admitted fact that the Complainant is the policy holder of LIC Jeevan Arogya (Table 903) bearing policy No.594615551. The Policy covers health care expenses. As per table 903. There was no exclusion ground in the table. The Opposite Party paid only Rs. 5,200/-(rupees five thousand two hundred)only on the account of the Complainant. The Complainant produced medical expenses bill of Rs. 26,631/-(Rupees twenty six thousand six hundred thirty one)only. On Dt. 03/09/2019 the Complainant sent a pleader notice to the Opposite Parties for settlement of the claim. But the Opposite Parties remained silent. When the policy is admitted and the Complainant produced bill, it was the duty of the Opposite Parties to settle the claim. Non settlement of claim of the Complainant amounts to deficiency in service on the part of the Opposite parties.
The issue is answered accordingly.
Issue No.2.
For deficiency in service of the Opposite Parties the Complainant is entitled to get relief. The Complainant produced bill of Rs. 26,631/-(Rupees twenty six thousand six hundred thirty one)only for medical expenses. The Opposite Parties paid Rs. 5,200/-(Rupees five thousand two hundred)only to the Complainant. Hence the Complainant is entitled to receive the rest amount of Rs. 21,431/-(Rupees twenty one thousand four hundred thirty one)only from the Opposite parties.
The issue is answered accordingly
As per supra discussion the following order is passed.
O R D E R
The Complaint is allowed on contest against the Opposite Parties. The Opposite Parties are directed to pay Rs. 21,431/-(Rupees twenty one thousand four hundred thirty one)only to the Complainant within 30 days from the date of this Order. Further the Opposite Parties are directed to pay Rs. 20,000/-(Rupees twenty thousand)only compensation for harassment and mental agony and Rs. 5,000/-(Rupees five thousand)only for litigation expenses to the Complainant.
Failing which the entire amount will carry 12% interest P.A. till realization.
Order pronounced in the open court on this 21st day of August 2023.
Supply free copies to the parties.
Typed to my dictation
and corrected by me.
I agree/-
( Smt. Anju Agrawal ) ( Jigeesha Mishra )
Dt.21/08/2023 Dt.21/08/2023
M e m b e r (w) P r e s i d e n t.
