C.C. No.373/2023

Ashok Mallick,

S/o. Dhadi Mallick,

At- Manatiri,

P.S.- Alando,

P.S.- Biridi,

Dist.- Jagatsinghpur.……… Complainant

1. The Branch Manager,

Star Health and Allied Insurance Co. Ltd.,

At- Cuttack Branch,

Dist.- Cuttack.

2. Star Health, Allied Company Limited,

Represented by General Manager,

1, New Tank Street, Valluvar Kottam,

High Road, Nungambakkam,

Chennai- 600034.…..…Opposite parties

For Complainant………..Mr. A. Mohanty, Advocate

For Opposite Parties………..Mr. S.P. Moharana & Associates

ORDER BY HON’BLE PRESIDENT- MR. P.K. PADHI:

                                                                                           JUDGMENT

            Complainant has filed the consumer complaint U/s.35 of C.P. Act, 2019 seeking following reliefs;

            “Direct the opposite parties to pay Rs.2,70,000/- along with 8% interest till date of payment towards cost of treatment expenses in the hospital, compensation for mental agony, cost of litigation.”

            Brief fact of the case of complainant is that, the complainant in order to secured the life of self and the family and to keep necessary protection from medical treatment being allured by the opposite parties, the complainant availed the policy in the name and style of Star Health & Allied Individual Insurance Policy for the year 2017-2018 bearing Policy No.1123021276004 of an amount of Rs.50,00,000/- having annual premium of Rs.32,350/- which was renewed from time to time and valid for the year 2023-2024. The complainant during subsistence of the policy faced an eye problem. As a result of which, the complainant was preferred to treated before the treating eye expert for which he was examined in Dr. Agreawals Eye Hospital on 18.8.2023 at Cuttack. As per the advice of the treating Doctor, the complainant undergone treatment in his right eye as a result of which complainant had took admission as indoor patient and discharged on 29.8.2023. After recovery from eye treatment the complainant lodged claim before the opposite parties for payment of medical expenses borne towards his treatment, which after verifying the same through their registered agent communicated on 15.9.2023 the complainant mobile number indicating therein, that the complainant is not entitled to get the mediclaim facility against his treatment, on the ground of pre-existing disease and on the date of operation the period of policy was not completed for 48 months.

             Opposite parties filed their written version stating as under;

            Due to the own fault of the complainant without supply the details of correct policy and information to the opposite parties his claim was not accepted due to wrong information supplied by the claimant and the same was rejected as per the terms and guidelines of the opposite parties.

            Complainant is no doubt a policy holder of opposite parties but merely because of numerical mistake in the communication the complainant should not have been harassed by the opposite parties and the opposite parties should have taken step to verify the number or could have asked for the original policy bond or could have cheque from their data base but simply rejecting the claim on the ground that the policy number is not of the complainant is not just and proper on the part of insurer. 

            Normally the claim of policy holder is very negligible and when any insurer claims the opposite parties/insurer should have taken utmost care to consider. The insurer who is in a difficult state might have committed mistake but when the policy bond has already been filed and brought to the notice, the opposite parties should have suo mutto considered the claim of complainant, but the opposite parties have failed to do so. So the inaction of opposite parties to settle the claim of complainant amounts to deficiency in service and unfair trade practice.

            We therefore direct the opposite parties to settle the claim of complainant and if any document is required the complainant shall be asked to furnish the same and the claim shall be settled within a period of 45 days from the date of passing of the order. We impose cost of Rs.3,000/- towards mental agony, harassment and impose cost of Rs.2,000/- towards cost of litigation. With the aforesaid observation and direction the consumer complaint is disposed of.

            Pronounced in the open Commission on this 26^th July,2024.