Orissa

Jajapur

CC/69/2021

Rashmibala Pratihari. - Complainant(s)

Versus

Managing director & CEO Manipal Cigna Health Insurance Co.Ltd. - Opp.Party(s)

Jeetendra Kumar Pratihari

21 Jul 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION :  JAJPUR.

Presents:-        1.    Smt. Susmita Mishra       President,

                                                            2.   Sri Bibekananda Das      Member (I/c).

Dated the 21st  day of July, 2023.

C.C. Case No. 69 / 2021.

Rashmibala  Pratihari, W/o:- Jeetendra Pratihari,

 At:- Binapani Sahi, P.O./P.S:- Jajpur Road

 Dist:- Jajpur.                       .  .  .  Complainant.

 

                                   Versus.

1. Managing Director & C.E.O,Manipal Sigma Health Insurance

Company Ltd,2^nd floor,Rajat Tower, 4/21main Block,Near

Reliance Jewel,Benguluru,Karnataka-560011

2. Regd.office-Manipal CIGNA Health Insurance Co.Ltd, 401/402,

    4^th Floor,Raheja Titenium,off western Express Highway Gurugaon East,Mumbai.

3. Branch Officer,Manipal CIGNA Health Insurance Co.Ltd,

Room No.13, 2^nd floor,Deendayal Bhawan, Ashok Nagar,Unit-2

Bhubaneswar, Khurda.751009

4. Chief Executive Officer, Sum Ultimate medicare ,K.-8.Kalinga Nagar,

Ghatikia, Bhubaneswar.Khurda.

5. Branch Manager,Union Bank of India, At.Station Road,

P.O/P.S-Jajpur Road, Dist.Jajpur..                            ...Opp. Parties.

 

                       Counsels appeared for the parties.           

                                   

For the Complainant :-             M/S J.K.Pratihari , Advocate & Associates,

For the Opp. Party No.1 to 3:- M/S Gunamani Panigrahi,Advocate &Associates.

For the Opp.Party No.4        :   None

For the Opp.Party No.5        :    Sushil Kumar Behera,Advocate & Associates.      

 

Date of filing Complaint        :-        05.07.2021,

Date of Argument                 :-          24.02.2023,

Date of Order                         :-          21.07.2023.

MR. BIBEKANANDA DAS, MEMBER (I/c) :-

            The C.C. Case has been filed U/S 35 of C.P.Act,2019 and taken up today for order. Since it is a year old case .We are disposing it on priority  basis as per mandate of C.P.Act,2019.

            Brief fact of this case is that, complainant took health Insurance Policy bearing policy No.100100502035 on dated 09.03.2020 which was valid up to dated 08.03.2021. During the policy suddenly the complainant suffered with eye related pain and consulted in L.V.Prasad Eye Institute and treatment was carried on dated 16.01.2021. The complainant during course of prescribed medicine prefer to wait  for one month for recovery. Due to further infection the complainant consulted Dr.P.S.Patra (Rhematologist) in SUM Ultimate Hospital,Bhubaneswar. On dated 23.02.2021 i.e on the same day the complainant was admitted and she produced the Health Insurance Certificate for the treatment before the Hospital Authority. The O.P.no.1 to 3 were informed by the Hospital authority for approval of sanction cash-less pre-authorization  vide Annexture-2 bearing No.23988224. During course of  treatment  O.P.no.1 to 3  were informed as per their requirement. The hospital authority  and the doctor complying the details of treatment as per their quarries and O.ps  had raised from date 25,02.2021 to 28.02.2021. On dated 28.02.2021 doctor advised to discharge and issued bill  o Rs.67,713/- which was sent to O.p.no.1 to 3 for approval  at 12.23P.M. On dated 28.02.2021 the complainant was not discharged for non-payment of bills by O.P.no.1 to 3 and she was detained and compelled to wait in the lobby.  That on dated 01.03.2021 at 7.45 p.m the O.P.no.1 and its media Assistant made a quarry that whether the patient still waiting in the hospital  or discharged on answer form .O.P.no.4 SUM Ultimate Hospital answered that “ the patient  still in hospital and waiting since last 29 hours and you are requested to do needful as early as possible”.

            As a matter of fact the complainant personally telephoned to the O.ps Toll free Number on dated 01.03.2021 from the said hospital, after she waited for more than 32 hours. For the approval, but the O.ps with ulterior motive  delayed the process in order to harass the complainant and ultimately on dated 01.03.2021 at about 10.30 P.M the O.ps denied the cashless claim of the complainant. After waiting for 35 hours  in the said hospital the O.p.no.1 to 3 repudiated the cash less insurance claim of the complainant at 10.30 P.m. The patient ( complainant) had lost her patience to wait further in the lobby, the O.P.no.4 forced her to pay instantly  the bill. Being harassed by the O.ps the complainant with much difficulty arranged money and paid Rs.67,813/- and thus she was harassed by O.P.no.1 to 3 and claimed for Rs.20,67,813/-  and Rs.10,000/- for cost with interest.

            We have gone through the records and perused all the documents available on record. We also gone through the averments of the written version filed by the O.P.no.1 to 3 and found that the O.ps have accepted the policy and treatment was done  after 9 to 11 months and as such it can not be presumed that pre-existence disease was there.  It is our considered view that the O.P.no.1 to 3 have committed deficiency in service and adopted unfair trade practice by repudiating cash less Insurance Claim of the complainant, which is illegal , arbitrary and goes negligence on part of the O.Ps. We therefore find from on the submission and pleadings of the complainant and the contentions of the O.ps are not  acceptable to this Commission and such irregularity of Insurance Authority  creates reasonable doubt in mind of the Commission and more over the complainant has not suppressed any material facts relating to her disease and treatment.  It is the bounden duty  if the insurer to indemnify the insured for the damage caused to her.

                                                            O R D E R.

In view of the above facts, and circumstances involved in this case, this Commission direct the O.P.no.1 to 3 to pay Rs.67,813/- along with interest @ 9% interest per annum from the date of claim, which is the bill amount paid by the complainant to O.P.no.4. Further it is directed that O.P.no. 1 to 3  shall also pay Rs.1,00,000/-  towards compensation and mental agony undergone by the complainant  and shall  also pay Rs.10,000/-  towards cost of this litigation to the complainant within a period of 30 days from the date of receipt of this order, failing which the complainant is at liberty to file execution proceeding against O.P.no.1 to 3  before this Commission as per C.P.Act,2019.  Hence the C.C.Case is allowed and accordingly disposed of.

                        Issue extract of the order to the parties for compliance.

                        Judgment pronounced in the Open Commission on this the 21st^d day of July, 2023.