Orissa

Cuttak

CC/131/2018

Meena Devi - Complainant(s)

Versus

Star Health and Allied Insurance Co Ltd - Opp.Party(s)

R K Pattanaik

10 Jun 2022

ORDER

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

                                                                C.C.No.131/2018

Mena Devi,

W/O:Sant Kumar,

C/O:Hemraj Jewellers,Naya Sarak,

P.O:Chandni Chowk,Cuttack-2.                                             ... Complainant.

        

                                                Vrs.

1.        Star Health & Allied Insurance Co. Ltd.

Represented through its Authorised Signatory-Claims,

No.15,Sri Sri Balaji Complex,

1^st Floor,Whites Lane,

Royapettah,Chennai-600014.

 

 

2.        Star Health & Allied Insurance Co. Ltd.

Represented through its Branch Manager,

Cuttack Branch Office,Plot No.1677(P)/1678(P),

Holding No.608,2^nd Floor,

Gajanan Complex,Dolamundai,

P.O:Buxi Bazar,Cuttack-1                  ....Opp. Parties.

 

Present:               Sri Debasish Nayak,President.

                                Sri Sibananda Mohanty,Member.

 

Date of filing:    26.12.2018

Date of Order:  10.06.2022

 

For the complainant:            Mr. R.K.Pattnaik,Adv. & Associates.

For the O.Ps.       :                  Mr. L.Sarangi,Adv. & Associates

 

Sri Debasish Nayak,President.                                     

            Case of the complainant in nutshell is that the complainant is a senior citizen and in order to secure her health hazards had taken a health insurance policy from the O.P. Insurance Company along with her husband under the plan called “Family Health Optima Insurance Plan” bearing policy No.,P/191212/01/2018/003521 which commenced from 23.9.17 to 20.9.18.  During subsistence of the said policy, the complainant was admitted to Manipal Hospital at Jeypore of Rajsthan for replacement of her knees.  The operation date was fixed to 27.8.2018.  The O.P  had given pre-authorization to the said hospital to the tune of Rs.1,00,000/- but quite strangely such authorization was withdrawn by the O.Ps on 31.8.18 on the ground that the complainant was having symptomatic for 10 years.  The complainant had to pay a sum of Rs.2,58,410/- towards the hospital expenses for replacement of her knees and was finally discharged on 1.9.18.  Thereafter on 29.9.18, the complainant had submitted all the relevant documents alongwith bills claiming for reimbursement of the amount spent by her to the tune of Rs.2,62,067/-.  On 19.10.18, the O.Ps had repudiated the claim of the complainant with a plea that the complainant was suffering from knee pain for the last 10 years which was not disclosed by her when the proposal of the policy was given and thus the claim was repudiated for suppression of the existing disease.  Moreso, the complainant had not completed 48 months after inception of the policy in order to avail the benefit of the policy. The complainant had again filed her claim for reconsideration by the O.Ps on 29.9.18 and ultimately had to file this case claiming her spent amount of Rs.2,62,067/- from the O.Ps alongwith interest @ 12% per annum with effect from 1.9.18 till realisation.  The complainant has further claimed from the O.Ps a sum of Rs.30,000/- towards her mental agony and harassment and a sum of Rs.20,000/- towards cost of the litigation.

2.         On the other hand, the O.Ps have contested this case and have filed their objection to the complaint petition.  As per the written version/objection of the O.Ps, they do not dispute the health insurance plan obtained by the complaint alongwith her husband which was in existence.  They also admit about the complainant being hospitalised at Jeypore Manipal Hospital on 27.818 for her Osteoarthritis, knee replacement and had raised the claim for cashless expenditure.  Initially the O.Ps had approved a sum of Rs.1,00,000/- but later on they had withdrawn the same by their letter dt.31.8.18 as because the complainant had pain at her bilateral knee for the last 10 years.  They also admit about the operation and the discharge of the complainant after replacement of her knees but since because the complainant had not disclosed about the pre-existing disease which is a condition to the proposal of the policy, the same was repudiated by them.  Thus they have prayed to reject the complaint petition being not maintainable.

3.         Keeping in mind the averments as made in the complaint petition and that in written version of the O.Ps, this Commission is of the opinion to settle the following issues in order to arrive at a proper adjudication.

            i.          Whether the case as filed by the complainant is maintainable?

ii.         Whether the complainant has cause of action to file this case?

            iii.        Whether there is any deficiency in service on the part of O.Ps.

iv.        Whether there was unfair trade practice adopted by the O.Ps.

            v.         Whether the complainant is entitled to the reliefs as claimed?

Issues No.1 & 2.

            For the sake of convenience issues no.1 & 2 are taken up together first for consideration here in this case.

            It is not disputed that the complainant is a consumer who had obtained a health insurance policy alongwith her husband in the name and style as “Family Health Optima Insurance Plan” bearing policy No.,P/191212/01/2018/003521 which commenced from 23.9.17 to 22.9.18.  It is also not disputed that the complainant due to pain in both of her knees had undergone surgery of knee replacement at Manipal Hospital of Jeypore,Rajasthan during the existence of the said policy.  Admittedly when the claim was made by the complainant towards her policy, it was repudiated.  Thus, it is noticed that the complainant has cause of action to file this case and her case is maintainable.

Issues No.3 & 4.

            The claim of the complainant was repudiated by the O.Ps on the ground that she had suppressed the fact that she was having knee pain for the last 10 years which she was supposed to disclose when the health insurance proposal was made by her and the policy was undertaken.  This plea as taken by the O.Ps, is not amply proved through proper evidenced as noticed.  It is because, by simply taking the plea that the complainant had knee pain for the last 10 years which she had suppressed would not suffice without proper evidence in proving the same on the part of the O.Ps.  Onus lies very much upon the O.Ps to prove the pleas taken by them that infact the complainant had knee pain for last 10 years which she had suppressed.  In the absence of such proof, it can never be concluded here that the claim of the complainant was repudiated bonafidely.  Thus, this Commission is of a considerate view here in this case that by repudiating the claim as made by the complainant towards reimbursement of her expenses for her knee replacement at Manipal Hospital of Jeypore,Rajasthan, the O.Ps have definitely caused deficiency in service and thereby the O.Ps had adopted unfair trade practice.  These two issues are thus answered in favour of the complainant and against the O.Ps.

Issue No.5.     

From the above discussions, it is observed here that the complainant is entitled to the benefits as claimed by her.  Hence it is so ordered;

                                                            ORDER

            The case is decreed on contest against the O.Ps.  The O.Ps are found jointly and severally liable.  They are directed to reimburse immediately the expenditure incurred by the complainant at Manipal Hospital,Jeypore in Rajasthan to the tune of Rs.2,62,067/- together with interest @ 9% per annum from 1.9.2018 till the amount is quantified.  The O.Ps are further directed to pay a sum of Rs.30,000/- towards mental agony and harassment as caused to the complainant and also to bear a cost of Rs.20,000/- towards the litigation cost of the complainant.

            Order pronounced in the open court on the 10^th day of June,2022 under the seal and signature of this Commission.

                                                                                                                                                                                                                                                 

                                                                                                                              Sri Debasish Nayak

                                                                                                                                        President

                                                                                                                       

                                                                                                                            

                                                                                                                         Sri Sibananda Mohanty

                                                                                                                            Member.