DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

 

Complaint Case No : CC/190/2020

Date of Institution : 08.09.2020

Date of Decision : 07.02.2022

Ramesh Kumar aged about 60 years son of Janak Raj H.No. B-X 465, Patel Nagar, Street No. 1, Barnala, Tehsil & District Barnala, Punjab. 

                           …Complainant

Versus

1. Aditya Birla Health Insurance Co. Limited, Registered Office; R Tech Park, 10th Floor, Nirlon Compund, Off Western Express Highway, Goregaon East, Mumbai-400063, through its Manager/Authorized Signatory. 

2. HDFC Bank Limited, Pucca College road Barnala, Tehsil & District Barnala, Punjab, through its Branch Manager/Authorized Signatory; 

           …Opposite Parties

 

Complaint Under Section 35 of Consumer Protection Act, 2019.

Present: Sh. Gagandeep Garg Advocate counsel for complainant.

Sh. Anuj Mohan Advocate counsel for opposite party No. 1.

Sh. A.K. Jindal Advocate counsel for opposite party No. 2. 

Quorum.-

1. Sh. Ashish Kumar Grover : President

2. Sh. Navdeep Kumar Garg : Member

 

(ORDER BY ASHISH KUMAR GROVER PRESIDENT):

    The complainant Ramesh Kumar has filed the present complaint under Section 35 of the Consumer Protection Act 2019 against Aditya Birla Health Insurance Company and others (in short the opposite parties). 

2. The facts leading to the present complaint are that the complainant is permanent resident of Barnala and has one saving account bearing No. 50100018162911 with the opposite party No. 2 and the opposite party No. 2 issued one credit card facility to the complainant for his personal use. As such, the complainant is using one credit card bearing No. 4893772402816330 issued by the opposite party No. 2. It is further alleged that in the month of March 2018, one agent from the call center office of the opposite party No. 1 called the complainant and told that there is one offer of insurance policy and it was also told that they have one tie up with the opposite party No. 2 being intermediary of opposite party No. 1 i.e. HDFC Telesales Phone Banking and its intermediary code is 2100639. It was told by the agent that complainant will have to pay a total amount of Rs. 6,684/- as one single premium and complainant will be insured for the period of 2 years. It is further alleged that the said policy will insured the complainant for Rs. 25,00,000/- and policy will covers the risks of Accidental in Patient Hospitalization Cover, Accidental Medical Expenses, Broken Bones Benefit, Burn Benefits, Coma Benefits, Temporary Total Disablement, Worldwide Emergency Assistance Service (Including Air Ambulance). It was also told by the agent that Temporary Total Disablement will be available on payment of additional premium and to get that benefit there is no formality, only additional premium will have to pay and complainant will get benefit against temporary total disablement where insured is unable to engage in any employment or occupation because of an accident on a temporary basis. A weekly benefit of Rs. (5000 or 10,000 or 7500)/per week maximum upto 100 weeks shall be payable. On believing the words of agent of opposite party No. 1 complainant purchased that medical insurance policy through opposite party No. 2 under the plan “Health Insurance Policy, Active Secure Policy” vide policy No. 12-17-0011774-00 and had paid the net premium of Rs. 6,684/- vide EMI from credit card and the said policy was valid from 23.3.2018 to Mid Night 24.5.2018 for a sum assurance of Rs. 25,00000/- at Barnala. As per the plan the said policy also covers Accidental Inpatient Hospitalization upto Rs. One Lack and Broken Benefits upto Rs. 1,00,000/- and Burn benefit upto Rs. 3,00,000/-, Temporary Total Disablement upto Rs. 5,000/- per week of complainant. 

3. It is further alleged that on 28.8.2019 the complainant met with an accident while he was going on his scooter in market at Barnala one dog came in front of complainant's scooter and due to that accident the complainant got left ankle fracture and admitted to Dr. Pardeep Sharma Hospital, Orthopedic, K.C. Road, Barnala, where Dr. diagnose Medical Malleolar Left Ankle Injury, which means break on inner bone of ankle for which the complainant remained admitted from 28.8.2019 to 1.9.2019 and during treatment one operation of the fractured ankle was also done by the said doctor on 29.8.2019 and doctor inserted one Screw in the bone. The complainant on 1.9.2019 discharged from the hospital after paying the entire amount in cash to the above said doctor. Thereafter, the complainant remained on the bed for 6 weeks and remained under treatment till 15.10.2019. During the said period complainant spent an amount of Rs. 28,800/- for his treatment. It is further alleged that being insured the complainant had sent all the documents including claim form to the opposite party No. 1 for reimbursement of claim amount. The opposite party No. 1 demanded some more documents which has also been sent by the complainant through DTDC Courier vide C/N No. Z23360097 dated 3.12.2019 and the same was received by the opposite party No. 1 and issued one claim No. 612190001065. Thereafter, the complainant approached the opposite parties No. 1 & 2 number of times, but they lingered on the matter on one pretext or the other. The said act of the opposite parties is deficiency in service. Hence, the present complaint is filed seeking the following reliefs.-

i) The opposite parties may be directed to pay the genuine claim of Rs. 28,800/- and an amount of Rs. 30,000/- @ Rs. 5,000/- for 6 weeks (in total Rs. 58,800/-) alongwith interest @ 18% per annum from deposit of documents i.e. 3.12.2019 till realization.  

ii) To pay Rs. 50,000/- on account of compensation for mental agony and harassment. 

iii) To pay Rs. 15,000/- as litigation expenses.  

4. The opposite party No. 1 filed written version by taking preliminary objections on the grounds of maintainability, no consumer dispute, suppression of material facts, no cause of action, jurisdiction etc. In the preliminary objections it further submitted that the complainant was bound by the terms and conditions of the policy while submitting the claim. However, complainant failed to submit the requisite documents as per terms and conditions of the policy. 

5. On merits, it is admitted that the answering opposite party received proposal form from the complainant for purchasing health insurance policy. The complainant never contacted the answering opposite party either on phone or personally nor made any complaint in writing regarding the act and conduct of the advisors who sold the policy. It is further submitted that the complainant failed to submit certain documents for reimbursement of his claim for which letter dated 29.1.2020 was sent to him informing about the requirements of the documents. All other allegations of the complainant are denied. Therefore, the opposite party No. 1 prayed for the dismissal of present complaint.

6. The opposite party No. 2 also filed written version by taking legal objections interalia on the ground that the complainant has not come to the Commission with clean hands, present complaint is frivolous, vexatious and is liable to be dismissed under Section 36 of the CPA, complainant has got no locus-standi or cause of action etc. On merits, it is admitted that the complainant having saving account and having credit card with the opposite party No. 2. The complainant himself paid alleged premium to the opposite party No. 1 directly. The complainant never approached to the answering opposite party nor the answering opposite party is liable for any alleged claim, as the complainant himself purchased the alleged policy from the opposite party No. 1 and the opposite party No. 2 has nothing to do in the entire transaction of obtaining insurance policy by the complainant. Therefore, the opposite party No. 2 also prayed for the dismissal of complaint. 

7. The complainant in support of his complaint tendered into evidence his own affidavit Ex.C-1, copy of policy schedule Ex.C-2, copy of OT notice Ex.C-3, copies of Lab tests Ex.C-4 to Ex.C-6, copies of bills Ex.C-7 to Ex.C-13, copies of prescription slips Ex.C-14 & Ex.C-15, copy of final bill and receipt Ex.C-16  & Ex.C-17, copy of Discharge Card Ex.C-18, copy of Doctor report Ex.C-19, copy of courier slip Ex.C-20, copy of Aadhaar Card Ex.C-21. Complainant has filed rejoinder to the written version of opposite party No. 1. Ld. Counsel for complainant on 15.3.2021 has suffered the statement that he does not want to file any rejoinder against the written version of opposite party No. 2 and closed the evidence. 

8. In order to rebut the case of complainant, the opposite party No. 1 tendered into evidence copy of letter of authority Ex.O.P1/1, copy of policy document Ex.O.P1/2, copy of claim form and medical documents Ex.O.P1/3, copy of deficiency letter Ex.O.P1/4, copy of repudiation letter Ex.O.P1/5, affidavit of Abhinandan Sharma Ex.O.P1/6 and closed the evidence. 

9. The opposite party No. 2 also tendered into evidence copy of Application Form Ex.O.P2/1, copy of customer offer Ex.O.P2/2, copies of statement of accounts Ex.O.P2/3 to Ex.O.P2/5, copies of statement of accounts Ex.O.P2/6 to Ex.O.P2/7, copy of terms and conditions Ex.O.P2/8, copy of cardmember agreement Ex.O.P2/9, affidavit of Harpreet Nath Ex.O.P2/10 and closed the evidence. 

10. We have heard the learned counsel for the parties and have gone through the record on the file. Written arguments filed by the parties. 

11. It is admitted case by the opposite party No. 1 that the complainant has taken the alleged health insurance policy for the period of 23.3.2018 to 22.3.2020 (wrongly mentioned in complaint as 23.3.2018 to 24.5.2018) from the opposite party No. 1. It is admitted by the insurance company that the complainant has lodged his claim with the opposite party No. 1. The complainant mentioned in the complainant that he has supplied all the documents to the opposite party No. 1, which was demanded by the them through DTDC Courier vide C/N No. Z23360097 dated 3.12.2019 i.e. Ex.C-20 and the same was delivered to the opposite party No. 1 and the opposite party No. 1 has also issued one claim No. i.e. 612190001065. On the other hand, the opposite party No. 1 submitted that they issued letter dated 29.1.2020 vide which demanded certain documents for settlement of claim and thereafter the opposite party No. 1 has also sent a letter dated 30.3.2020 vide which the opposite party No. 1 repudiated the claim of the complainant. But the opposite party No. 1 failed to produce any postal/courier receipt to establish that they have sent the above said letters to the complainant. The complainant has produced the medical bills Ex.C-7 to Ex.C-13 and final hospital bills Ex.C-16 & Ex.C-17. The complainant has also produced the discharge card Ex.C-18 in which the doctor has advised him complete rest for 6 weeks. The opposite parties have not rebutted the same. As such, it is established that due to the surgery of fractured bone the complainant was temporary disabled for 6 weeks. 

12. The complainant has Exhibited number of documents of his treatment and other relevant documents on the file. All the documents have been supplied to the opposite party No. 1 despite that the insurance company has repudiated the rightful claim of the complainant, which is clear cut deficiency in service on the part of the opposite party No. 1. 

13. On the other hand, the opposite party No. 2 has denied the case of the complainant, as the complainant himself paid the alleged premium to the opposite party No. 1 directly and the opposite party No. 2 has no concern with the present case. The complainant has failed to produce any evidence to establish the liability of the opposite party No. 2. Therefore, the present complaint is dismissed qua the opposite party No. 2. 

14. In view of the above discussion, the present complaint is partly allowed against the opposite party No. 1 and the opposite party No. 1 is directed to pay Rs. 58,800/- to the complainant alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization. The opposite party No. 1 is also directed to pay Rs. 10,000/- as compensation on account of mental agony and harassment to the complainant and Rs. 5,500/- as costs. Compliance of the order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of this order be supplied to the parties free of costs. File be consigned to the records after its due compliance.  

ANNOUNCED IN THE OPEN COMMISSION:

        7th Day of February, 2022

 

 

            (Ashish Kumar Grover)

            President             

 

 

(Navdeep Kumar Garg)

Member