Complainant/s:             Mailarappa S/o Ningappa    

                                       Heggappanavar, Age:66 Years,

                                               Occ: Agriculture and Business,

                                               R/o Tambragundi, Taluk: Mundargi,

                                               Gadag District.

                                            (Reptd., by Sri.S.K. Patil, Advocate)   

V/s

ORDER

JUDGEMENT DELIVERED BY SMT.SAMIUNNISA .C.H. PRESIDENT:

This complaint is filed by the complainant against the OPs by invoking Sec 35 of the Consumer Protection Act, 2019.

             The averments of the complaint in brief are:

         2.  The above complaint is filed by the complainant stating that, he insured health claim with OP No.1 through OP No.2 under Policy No.2842/00143716/0102/000/00 and claim No.MHC028052 covering himself and his wife.  It is further submitted that, he married with one Shobha @ Annapurna on 16.04.2017 as per Hindu customs.  Before marriage the name of his was called as Shobha in all her school records etc., and her name was mentioned as Shobha at the time of marriage and called by complainant and his family members as Annapurna @ Shobha both Annapurna and Shobha belongs to one person that is the wife of complainant.  It is further submitted that, complainant is a consumer of OPs as the OP No.1 is the insurer and complainant is the insurer along with his wife Shobha @ Annapurna.  It is further submitted that, the wife of complainant was diagnosed with primigravida with B28 weeks gestation with vertex presentation with Dengue Fever with bronchiectasis in septic shock for safe confiment.  Complainant insured his health for Rs.2,00,000/- including his wife i.e., spouse policy for the period from 19.01.2018 to 18.01.2019.  Due to the above said disease, the wife of complainant admitted to Ashray Hoispital, Gadag on 30.10.2018 and she was discharged on 08.11.2018 i.e., during the policy was in force and incurred expenditure of Rs.1,50,000/- for Hospital charges, lab charges, medical bills and Rs.50,000/- towards transportation and attendant charges.  It is further submitted that, complainant submitted all the relevant papers like claim form, health certificate of insurance issued by OP No.1, discharge summary, affidavit, medical bills, lab reports, scan reports, marriage card, x-ray reports etc., to OPs for the claim of insurance amount but, he received the letter from OPs on 22.12.2018 stating that, claim has been repudiated with a remark that, the name of complainant’s wife is stated as Shobha in the insurance policy, but in the Hospital records her name has been mentioned as Annapurna W/o Mailarappa Heggappanavar, the same is not legal and which is not sustainable in law because the OPs have collected premium for the said policy and in the health claim insurance it is clearly mentioned that the relationship with insured as a spouse and hence, the complainant is entitled for the sum insured amount and the compensation.  It is further submitted that, the name of complainant’s before marriage is called as Shobha and at the time of insurance, the records have been submitted and at the time of marriage she called by the complainant’s family as Annapurna.  The type of policy is family floater (Self + spouse) and therefore, the complainant is entitled for the claim amount of Rs.2,00,000/- and compensation.   It is further submitted that, the complainant has submitted all the papers to the OPs but, the OPs repudiated the claim as stated supra which is a deficiency of service and the complainant has suffered mentally and financially for the repudiation made by the OPs.  Therefore, the Complainant got issued legal notice on 05.02.2020 to OPs calling upon them to make payment of sum insured, but it went in vain.  The cause of action for this complaint arose on 05.02.2020, when the notice has been issued to the OPs, which is a deficiency of service on the part of OPs and hence, prayed to allow this complaint.

          3.   In pursuance of the notice issued by this Commission, the OP No.1 and 2 appeared through their counsels and filed their written version.

                                  Written Version of OP No.1     

          4.       It is submitted that, the complaint filed by the complainant is not maintainable either on law or on facts.  It is further submitted that, the complainant has taken health insurance policy with OP No.1 under Policy No.2842/00743716/002/000/00 which is a family health care-VFD plan and the name of the primary insured is complainant and his wife Shobha with date of birth as 14.06.1997 mentioned in the policy was covered under floater sum insured Rs.2,00,000/-, the same was issued subject to terms and conditions.  It is further submitted that, the complainant lodged claim with OP No.1 under the above mentioned policy with documents.  At the time of verification in the insurance policy, it came to know that, the name of wife of complainant is Shobha with date of birth as 14.06.1997 but, the hospital documents submitted by the complainant, the person who has taken treatment is mentioned as Annapurna and the date of birth mentioned as 29.03.1989 and so also the School records of said Shobha discloses the date of birth as 03.07.1998.  Hence, the spouse name of complainant does not tally with the name mentioned in the documents submitted by the complainant.  It is submitted that, since there is a difference in the name of person insured and the name of person who has taken treatment, the OP No.1 has rightly repudiated the claim which was informed through their letter dated 22.12.2018 and hence, the complainant is having no right to claim under the policy for the person who is not covered/insured under the policy.  It is further submitted that, the complainant has produced one document alleged to the resident certificate issued by the village accountant, Thambragundi mentioning that Annapurna W/o Mailarappa Heggappanavar is resident of Thambragundi village, Mundargi Taluk and village accountant is not having any power under any law to issue such alleged certificate and the said not admissible under the law.  Therefore the claim submitted by the complainant is not admissible for any claim or relief and therefore, prayed for dismissal of the complaint.

Written Version of OP No.2

          It is submitted that, the complaint filed by the complainant is false and not tenable either in law or on facts.  It is respectively submitted that, the complainant is neither a complainant nor he is allegedly aggrieved by the alleged deficiency of service.  It is partly true to say that, the complainant is insured with Health Claim with OP No.1 and the policy number as described in para No.1 of the complaint is not true and correct. The contents of para No.2 and 3.  It is further submitted that, the complainant has not mentioned any reports based on which he relied and made such assertions.  It is further submitted that, the complainant has insured health claim policy for Rs.2,00,000/- including spouse for the policy period from 19.01.2018 to 18.01.2019.  It may be true that, the complainant has submitted claim form with OP No.1 and may also be true that, the OP No.1 has repudiated the claim of the complainant on the ground that, the name of the spouse/wife of the complainant mentioned policy is different than the name of patient in the Hospital records.  For the said flaw of mentioning of two different names at two separate places, this OP is not at all responsible.  This OP rectify the alleged names of the wife of complainant that have been mentioned either in the policy or in the Hospital records.  As far as repudiation of the policy is concerned, this OP has no role to play.  It is not true to say that, the complainant has submitted all the papers of claim to this OP.  Further it is not true to say that, the complainant suffered mentally and financially by the repudiation of claim.  It is submitted that, the policy in question is issued by the OP No.1 to the complainant and it is for the complainant to satisfy the claim terms and conditions as required by the insurance company/OP No.1 and it is the OP No.1 at his disposal, has to settle the claim amount as per his service terms.  This OP has no role to play either in the said repudiation of the claim or in the payment of the alleged claim amount.     Under the circumstances, the complaint against this OP is not maintainable and the complainant is not at all entitled for any reliefs and hence, prayed for dismissal of the complaint.

         5.  The complainant filed his Chief affidavit along with 116 documents.  The Law Officer of OP No.1 has filed chief affidavit and Service manager of OP No.2 filed chief affidavit with 03 documents. 

    COMPLAINANT FILED DOCUMENTS AS follows

          OPs FILED DOCUMENTS AS follows

         6.   On pursuance of the materials, placed by the complainant and OPs, the following points arises for our consideration:-

1. Whether the complainant has proved the deficiency in service

On the part of the OPs as averred in the complaint and entitled to any relief?

2. What Order?

    7.       Our findings to the above points are:-

              Point No. 1:  Negative.

              Point No. 2:  As per the final Order

R E A S O N S

           8.  POINT NO.1:  The complainant has filed this Complaint against the OPs seeking relief for repudiation of the mediclaim by the OPs.  The policy itself is a mediclaim spouse policy.  In the policy, the name of wife of the complainant has been mentioned as Shobha but, in the documents i.e., ID Card and other documents her name is mentioned as Annapurna Heggappanavar.  The submission of the complainant is that, after the marriage, the name of wife of the complainant has been changed.  By virtue of that, the name has been mentioned as Annapurna.  To show same, complainant has produced Wedding Card and the School Certificate belongs to his wife to prove that, Shobha and Annapurna are one and the same.  On the other hand, OP submits that, not only the name of wife of the complainant, the age and name of her father is also change.  The documents which has been produced before them i.e., declaration affidavit given to OP, the name of the father is also change.  The date of birth mentioned ion the School records and in the Aadhar Card is also different. 

          9.       On-going through the records placed before the Commission, in the Wedding Card, both the names have been mentioned and even the School records also produced to show that, previous name of the complainant’s wife is Shobha.  During their marriage, the card has been printed as Shobha as well as Annapurna.  In one way it can be admitted that, Annapurna and Shobha is one and the same but, the date of birth and father name of wife of complainant is also change.  Hence, Commission comes to the conclusion that, the repudiation of OP is just and proper.  Hence, we answer Point No.1 in Negative.

        10.  POINT NO. 2: In view of our findings on the above points, the complaint filed by the complainant is partially allowed. In the result, we pass the following: 

//O R D E R//

          1.  The above Complaint is dismissed.  The parties to bear their own cost.

          2. Send the copies of this order to the parties free of cost.

           (Dictated to the Stenographer, transcribed by him, corrected and then pronounced by me in the Open Court on this 30^th day of October-2021)

,         (Shri B.S.Keri)                              (Smt.C.H.Samiunnisa Abrar)

               MEMBER                                               PRESIDENT