Orissa

Sambalpur

CC/56/2021

Smt. Sujata Sahoo - Complainant(s)

Versus

1. Divisional Manager, United India Insurance Company LTD. - Opp.Party(s)

Sri. P.K.Padhee & Sri. R.Gupta

28 Mar 2023

ORDER

PRESIDENT, DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

CONSUMER.COMPLAINT NO.- 56/2021

Present-Dr. Ramakanta Satapathy, President,

  Sri. Sadananda Tripathy, Member

 

                       Smt. Sujata Sahoo,

W/o- Panchanan Sahoo,

R/o/PO-Chiplima, PS-Burla,

Tahl/Dist-Sambalpur.                                                 …………..…..Complainant

 

Vrs.

1. Divisional Manager, United India Insurance Company Limited

Gaiety Road, PO/Ps-Sambalpur,

Dist-Sambalpur-768001.

2. Good Health Insurance TPA Limited,

Plot No. 49, Nagarjuna Hills, Punjagutta,

Hyderabad, 500082, Telengana.

3. Branch Manager, Andra Bank(At present Union Bank),

At-Dalab, PO-Kadobahal, Ps-Bheden,

Dist-Bargarh-768104.                                             …..…..….Opp. Parties

Counsels:-

1. For the Complainant         :-         Sri. P.K.Padhee, Advocate & Associates.
2. For the O.P. No.1              :-         Sri. S.A. Guru, Advocate & Associates.
3. For the O.P. No.2 & 3      :-         Ex-parte

 

Date of Filing:27.10.2021,  Date of Hearing :21.02.2023, Date of Judgement : 28.03.2022

Presented by Sri Sadananda Tripathy, Member.

1. The case of the Complainant is that the husband of the Complainant has a savings bank account in the Andhra Bank, at present Union Bank Dalab, Dist Bargarh vide account No. 286910100004861. In the year, 2016 the then Bank Manager of the said bank introduced the husband of the Complainant about Andhra Bank Aarogya Daan Policy of health Insurance coverage and as such the husband of the Complainant interested to take insurance coverage for his entire family and applied in necessary forms and submitted the same before the Bank and good Health Id No. GHUIAB02421155 was generated and the inception of the said policy started from dt. 20.12.2016 in the name of the Complainant and a sum of Rs. 1713/- was deducted from the account of the husband of the Complainant for the said insurance coverage on dt. 20.12.2016. Further a sum of Rs. 3657/- was deducted on dt. 08.06.2017 by the OP No. 3 and paid to OP No. 2. Moreover a sum of Rs. 4878/- was deducted on 08.06.2018 towards the premium amount and was paid to the OP No. 2 by OP No. 3. All the above amount have been debited from the account of the husband of the Complainant on the dates mentioned above and for each year since 2016 to 2018. Three numbers of health cards from the period from 2016-17, 2017-18 and 2018-19 were issued in favour of the Complainant. The OP No. 2 is a subsidiary under OP No. 1 and used to give insurance coverage for health to the citizens of the different states of India. The OP No. 2 has been registered under TPA License No. 23. The Complainant felt mild colic pain coupled with back pain during the month of September 2017 for which she consulted her doctor on 28.09.2017 and the treating physician advised the Complainant to have a ultrasound of abdomen and pelvis and accordingly the Complainant tested herself at Gupta Diagnostic clinic on the next day i.e. 29^th Sep, 2017 and found chronic cholecystitis with cholelithiasis. The doctor advised the Complainant to consult with a surgery specialist due to operation of Gallstone. The Complainant underwent an operation in Gupta Nursing Home Burla due to her Gallstone on 30.10.2018 and she was discharged on 02.11.2018 by paying a sum of Rs. 25,636/- vide money receipt No. 15 dt. 01.11.2018 towards bill No. 3. It was a pre-condition of the booklet/guide book issued by OP No. 2 that the insured person shall enjoy the cashless facility for taking treatment in the network hospitals listed TPAs members’ guide book and accordingly on the date of admission the Complainant informed about the insurance to the authority of Gupta Nursing Home and accordingly Gupta Nursing Home Burla intimated the OP No. 2 on the same day about  the admission of the Complainant and in response thereto the OP No. 2 sent a mail to Mr. Rajkishro Jajodia in his mail to have received and declaration form along with pre authorization request form. Further in the said mail the OP No. 2 informed Mr. Jajodia that the representative of the OP No. 2 will follow up on the same and get in touch with Gupta Nursing Home as soon as possible. The said mail reply has been purported to have been received by Mr. Jajodia on 01.11.2018 at 10.08 a.m. Even after receipt of information about the admission of the Complainant neither the OP No. 2 nor any of his representatives ever followed about the health condition of the Complainant for which the Complainant and her husband had no other alternative but to pay the entire expenses of medical treatment i.e use and occupation charges, operation charges, attendant charges amounting to Rs. 25,636/- to the said nursing home on dt. 02.11.2018 though the said health insurance coverage was cashless. When no response was made by the OP No. 2 the Complainant duly applied in claim form on 03.11.2018 annexing all documents. Even after receipt of the documents to show that the Complainant underwent an operation, the OP No. 2 dragged the matter with baseless letters and did not settle the claim which is crystal clear from the case of the Complainant which attracts deficiency in service for which the OPs are liable to pay compensation to the Complainant.
2. The Written Statement of the O.P No. 1 is that the Complainant did not disclose or relied on or supplied a single piece of paper, she did not give health insurance policy number, her father in law & mother in laws medical paper, nor disclosed during the tenure of 2018-19 policy regarding her colic pain and chronic cholecystitis with cholelithiasis, which was nothing but fraud and due to these facts if at all there was a policy, the insurance company is not liable to indemnify the insured due to non-disclosure of fact and fraud in general. Due to different facts and reasons cashless facilities available in TPAs list keep changing and it is not within this OP’s knowledge that Gupta Nursing Home, Burla have such facilities. It is not known to this OP that Gupta Nursing Home, Burla intimated the OP No. 2 on 30.10.2018 about admission of the Complainant and in response thereto the OP No. 2 sent a mail to Rajkishore Jajodia in his mail to have received the declaration from along with pre-authorization request form and that the OP No. 2 informed Mr. Jajodia that the representatives of the OP No. 2 will follow up on the same and get in touch with Gupta Nursing Home as soon as possible and the same has been received by Mr. Jajodia on 01.11.2018. The petition discloses Third Party Administrators has asked the Complainant, to submit some documents which they failed to do. As the Complainant has not responded to supply the necessary information for processing of the claim might have been closed. As per the IRDA Regulations, 2001 Act the TPA has to process the claim and accordingly there will be settlement of individual cases. As no documents supplied in this case, the Complainant has not supplied the relevant documents and not cooperated with the Third Party Administrators for settlement of claim, the claim was closed due to non cooperation of Complainant. The Complainant come up with false allegations and suppressed material fact which is nothing but abusing the processes of Court and fraud upon Court, hence the OP is not liable to reimbursement of the entire claim of the Complainant along with compensation and cost for the financial loss, mental agony and harassment. It is both frivolous and vexatious and for this, the complaint needs be dismissed with cost under of the CP Act.  

The other OPs have not given their Version.

3. From the version and submission of the parties and From the supra discussion it is clear that It was a pre-condition of the booklet/guide book issued by OP No. 2 that the insured person shall enjoy the cashless facility for taking treatment in the network hospitals listed TPAs members’ guide book and accordingly on the date of admission the Complainant informed about the insurance to the authority of Gupta Nursing Home and accordingly Gupta Nursing Home Burla intimated the OP No. 2 on the same day about  the admission of the Complainant and in response thereto the OP No. 2 sent a mail to Mr. Rajkishor Jajodia in his mail to have received and declaration form along with pre authorization request form. Further in the said mail the OP No. 2 informed Mr. Jajodia that the representative of the OP No. 2 will follow up on the same and get in touch with Gupta Nursing Home as soon as possible. The said mail reply has been purported to have been received by Mr. Jajodia on 01.11.2018 at 10.08 a.m. Even after receipt of information about the admission of the Complainant neither the OP No. 2 nor any of his representatives ever followed about the health condition of the Complainant for which the Complainant and her husband had no other alternative but to pay the entire expenses of medical treatment. It is the primary duty of the OPs to take necessary immediate action as a valid Mediclaim Policy/Scheme of the Complainant taken from the OPs. As the Insurance Company, the OP No. 1& 2 are liable for deficiency in service. As the OP No. 3 is the Bank, is not liable for the same.

 Accordingly, it is ordered.

ORDER

The complaint is allowed against the O.P. No.1 & 2 and dismissed against other OP No.3 on part contest and on merit. The O.P. No.1 & 2 are directed to pay Rs. 25,636/- towards medical expenditure with 6% interest P.A. from the date of claim i.e 30.10.2018 to the Complainant. Further the OP No.1 & 2 are directed to pay an amount of Rs.20, 000/- towards mental agony and harassment as compensation and Rs. 5,000/- towards litigation expenses to the Complainant.  In case of nonpayment the amount will carry 9% interest P.A. from date of filing of complaint till realization.

Order pronounced in the open Court today on 28^th day of March, 2023.

Free copies of this order to the parties are supplied.