District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.498/2022.
Date of Institution: 14.9.2022.
Date of Order: 24.05.2023.
Narender Kumar S/o Shri ami Chand, age 38 Years, resident of village Ferozpur (64) Near Chaupal, Palwal, Haryana.
…….Complainant……..
Versus
Aditya Birla Health Insurance Co. Limited, 9th floor, Tower 1, One India Bulls Centre, Jupiter Mills Compound, 841, Senapati Bapat Marg, Elphinstone Road, Mumbai – 40013 through its branch/Manager/Divisional Manager/Authorized person.
…Opposite party……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana…………Member.
PRESENT: Sh. Tejinder Singh, counsel for the complainant.
Opposite party (defence struck off on dated 20.02.2023)
ORDER:
The facts in brief of the complaint are that the complainant was insured by the opposite party bearing policy No. 23-20-0108151-02 and the said policy was also valid at that time. The complainant was admitted to the Gaurav Hospital, Samay Pur Road, Ballabagarh Faridabad on 28.05.2022 with presenting complains of “High Grade Fever, Viral meningitis etc. fully describe in the discharge summary” and was discharged on 01.06.2022 from the hospital. The complainant had to spend a sum of Rs.70038/- on various pathological tests, x-rays, ultrasound, ward bed charges, consultant doctor charges RMO charges, nursing charges, medicine + iv fluids etc. The complainant had to spend the above said amount while his health insurance policy was active with the opposite party company. The complainant submitted all the original documents as required by the opposite party for claiming the above said amount. Opposite party approved the claim of the complainant RS.25,000/- on 29.05.2022 in this regard a pre-auth message also received on the mobile phone of the complainant. To utter shock of the complainant when a claim rejection letter was received from the opposite party i.e.the insurance company on 04.07.2022. The complainant had to spend a sum of Rs.70038/- on his treatment, hospitalization, medicines etc. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) reconsider the claim of the complainant and pay Rs.70038/- alongwith interest @ 24% p.a.
b) reinstate the policy of the complainant , if rejected.
c) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment .
d) pay Rs. 25,000 /- as litigation expenses.
2. Upon receipt of the complaint notices were sent to opposite party. Opposite party put in appearance through counsel. After availing seven effective opportunities reply had been filed on behalf of opposite party. Therefore, defence of opposite party was struck off vide order dated 20.02.2023.
3. We have heard Shri Rajiv Gill, counsel for the complainant and also have gone through the case file.
4. In this case the complaint was filed by the complainant against opposite party – Aditya Birla Health Insurance Co. Ltd. with the prayer to: a) reconsider the claim of the complainant and pay Rs.70038/- alongwith interest @ 24% p.a. b) reinstate the policy of the complainant , if rejected. c) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment . d) pay Rs. 25,000 /- as litigation expenses.
To establish his case he has led Annx.C-1 - insurance policy, Annx.C-2 – Discharge summary, Annx.C-3 – IPD Bill details, Annx.C-4 – wardsapp message, Annx.C-5 – letter dated 04.07.2022 regarding reimbursement claim ID 1122285038073 is rejected.
5. There is nothing on record to disbelieve and discredit the aforesaid evidence of complainant. Since opposite party had not filed written statement to contest claim of the complainant despite availing several opportunities, therefore, defence of opposite parties was struck off vide order dated 20.03.2023.. Hence the allegations made in complaint by the complainant go unrebutted.
6. During the course of arguments, Shri Naresh Vashishtha, counsel for the complainant has made a statement that “we are ready to receive Rs.60,000/- lump sum amount as the claim amount from the JD. Order may be passed accordingly.”
7. After going through the evidence led by the complainant as well as the statement of the counsel for complainant, the Commission is of the opinion that the complaint is allowed. Opposite party is directed to pay Rs.60,000/- in lumpsum to the complainant within 30 days from the date of receipt of copy of order. There are no order as to costs. Copy of this order be sent to the parties concerned free of costs. File be consigned to the record room.
Announced on: 24.05.2023. (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
