| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C.No.324 of 06.10.2022 Decided on : 08-05-2024 Janish Kumar S/o Jagdish Parshad R/o House No.MCB-Z3-2079, Saraswati Street, Amrik Singh Road, Bathinda. ........Complainant Versus Authorised Signatory/Chief Executive Officer, Aditiya Birla Health Insurance Company Limited, 9th floor, Tower-1, One World Centre, Jupiter Mills Compound, 841, Senapati Bopat Marg, Elphinstone Road, Mumbai Pin-400013. Aditiya Birla Health Insurance Company Limited, Fortunie Chamber, 7th Floor, SCO No.16-17, Ferozepure Gandhi Market Road, Ludhiana, Pin 144001 through its authorised person/competent person. Aditiya Birla Health Insurance Company Limited, having its Local Office at G.T Road Near Dr.Vandana Hospital, Bathinda, through its Authorised Person/Competent Person.
.......Opposite parties Complaint under Section 35 of the Consumer Protection Act, 2019 QUORUM Smt. Priti Malhotra, President Smt. Sharda Attri, Member Present : For the complainant : Sh.Jagdish Parshad, Advocate. For opposite parties : Sh.Bharat Goyal, Advocate. ORDER Priti Malhotra, President The complainant Janish Kumar (here-in-after referred to as complainant) has filed this complaint U/s 35 of Consumer Protection Act, 2019 (here-in after referred to as 'Act') before this Commission against Authorised Signatory/Chief Executive Officer, Aditiya Birla Health Insurance Company Limited and others (here-in-after referred to as opposite parties). Briefly stated, the case of the complainant is that on the allurement of the agent named Paramjit Singh and Mohit, on 23.3.2022, he purchased the policy bearing No.21-21-3029438-00 and ID No.PT85854494 known as 'Active Health Platinum Enhanced Plan' insurance plan worth Rs.5 lakhs valid from 23.3.2022 to 22.3.2023 for one year. It covers all the family members. The premium of Rs.11,272/- was paid in one installment. The policy type was family floater and policy category was new business. It is alleged that on 18.7.2022, the complainant suffered from serious headache and dubmness in the left side of the body and was taken to the All India Institute of Medical Sciences Bathinda for consultation on the same day. As per the instructions of the doctor, he was given the preliminary treatment and was advised various tests such as MRI and same were got conducted at Delhi Heart Institute and Multi Specialty Hospital, Bathinda. It is further alleged that as per the report of the test, the complainant was admitted to Gold Medical Hospital and ICU, Power House Road, Bathinda on 19.7.2022 and he remained admitted from 19.7.2022 to 25.07.2022 vide registration No.85 dated 19.7.2022. At the time of admission of the complainant, the information regarding same was given to opposite parties vide intimation No.1122285053616 through e-mail. The complainant was discharged from the hospital on 25.7.2022 and accordingly he submitted his claim on 1.9.2022 for Rs.76,864/- and also completed the other formalities. He also obtained the opinion from Dr.Abhishek on 28.7.2022 and as per his prescription, various tests were performed in the Delhi Hearth Institute and Multiplicity Hospital on 1.8.2022 and complainant was declared medically fit. It is further alleged that although, the complainant submitted his claim within time and completed all the formalities, but inspite of that, opposite parties rejected his claim vide their letter dated 22.9.2022 merely on the ground that there are discrepancies and lapses noted in the event of hospitalization related to headache parasthesea left side of body with syncopal attack. He again requested opposite parties vide e-mail dated 15.9.2022 for passing the claim and requested them to consider his claim that is rejected on merely technical grounds, but again vide their e-mail dated 27.9.2022, his claim was again rejected on the same grounds. The complainant got issued a legal notice dated 19.09.2022 calling opposite parties to meet his claim, but they did not give any reply to this notice. On this backdrop of facts, the complainant has prayed for directions to opposite parties to pay Rs.76,864/- as expenses incurred by him and Rs.2 lakhs as compensation and litigation expenses. Upon notice, opposite parties appeared through counsel and contested the complaint by filing written version and raising preliminary objections that the complaint is not maintainable since immediately on the receipt of the claim, it was duly registered, entertained and processed. On scrutiny of the documents, it has been observed that there were discrepancies and lapses noted in the event of hospitalization related to headache parasthesea left side of the body with the syncopal attack. As such, the claim of the complainant was repudiated vide letter dated 22.9.2022 on the abovesaid ground. The claim of the complainant was rightly repudiated as no claim and grounds of repudiation are legal, valid and enforceable and as per terms and conditions of the policy. There is no deficiency or negligence in service on part of opposite parties as they had not adopted any unfair trade practices. As such, the complaint deserves dismissal on this score only. The complainant is estopped by his own act and conduct from filing the complaint since he is not coming to the Commission with clean hands and had concealed and suppressed the material facts from this Commission that claim falls outside the purview of the policy. As such, he is not entitled to any discretionary relief from this Commission. No cause-of-action ever arose in favour of the complainant and against opposite parties to file the complaint. The complaint is not maintainable since the complicated question of law and facts are involved. They require elaborate evidence both oral and documentary and it is only civil court of competent jurisdiction that can try and decide the complaint. The complaint cannot be decided by this Commission in a summary manner. Opposite parties also reserve the right to produce any additional evidence at any stage of the proceedings before this Commission as and when they get to produce the same. On merits, opposite parties have reiterated their version as taken in the preliminary objections as detailed above and controverted all other averments of the complainant and prayed for dismissal of complaint. In support of his complaint, the complainant has tendered into evidence his affidavit dated 16.10.2022, (Ex.C45) and documents, (Ex.C1 to Ex.C44). In order to rebut the evidence of complainant, opposite parties have tendered into evidence affidavit of Richard Herish dated 4.9.2023, (Ex.OP1/1). We have heard learned counsel for the parties and gone through the file carefully. Learned counsel for parties have reiterated their stand as taken in their respective pleadings as detailed above. We have given careful consideration to these submissions. Admittedly, the complainant purchased the policy bearing No.21-21-3029438-00 from opposite parties vide Ex.C1. It covers all the family members of the complainant. Perusal of file reveals that the complainant had suffered from serious headache and dubmness in the left side of the body and he was taken to the All India Institute of Medical Sciences Bathinda on 18.7.2022 where on the advise of the doctor, various tests inlcuding MRI were done from Delhi Heart Institute and Multi Specialty Hospital, Bathinda. Ex.C3, proves this fact. Thereafter he was got admitted to Gold Medical Hospital and ICU, Power House Road, Bathinda and he remained admitted there from 19.7.2022 to 25.7.2022. Discharge summary, (Ex.C6) proves this fact. After discharge from the hospital, he informed regarding his admission and treatment and submitted his claim for Rs.76,864/- on 1.9.2022 to opposite parties. Opposite parties have rejected the claim vide letter dated 22.9.2022, (Ex.C39) on the ground that there are discrepancies and lapses noted in the event of hospitalization related to headache parasthesea left side of body with syncopal attack. The complainant has produced all the bills and payment receipts regarding the expenses incurred on his treatment, (Ex.C7 to Ex.C25). It proves that he has spent an amount of Rs.76,864/- on his treatment. A bare perusal of these bills and payment receipts reveals no discrepancies and lapses. Moreover opposite parties have not apprised or described in detail in their rejection letter to the complainant that which type of discrepancies and lapses were noted in the event of hospitalization related to headache parasthesea left side of body with syncopal attack. Therefore, we are of the considered opinion that the claim of the complainant is genuine one and opposite parties have wrongly repudiated the claim of the complainant. It amounts to deficiency in services and unfair trade practice on their part. In view of what has been discussed above, present complaint is partly allowed with Rs.10,000/- as cost and compensation. Opposite parties are directed to pay the claim amount of Rs.76,864/- to the complainant. The compliance of this order be made within 45 days from the date of receipt of copy of this order. In case of non-compliance of the order within the stipulated period, thereafter opposite parties will be liable to pay additional cost of Rs.20,000/- to the complainant. The complaint could not be decided within the statutory period due to heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record room. Announced 08-05-2024 - (Priti Malhotra)
President (Sharda Attri) Member
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