DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .
Complaint No. 189
Instituted on: 24.05.2023
Decided on: 11.03.2024
Gurjeet Giri aged about 42 years son of Surjit Giri, resident of H.No.326, Haripura Basti, Ward No.2, Sangrur.
…. Complainant.
Versus
1. Aditya Birla Health Insurance Company Limited, 10th Floor, R-Tech Park, Nirlon Compound Next to HUB Mall off West Express Highway, Goregaon East, Mumbai-400063 through its Managing Director.
2. The Manager, HDFC Bank Limited, Branch Office: Kaula Park, Sangrur through its Branch Manager.
3. Dr. Jagmohan Hospital, Near Fly Over, Dhuri Road, Sangrur through Dr. Jagmohan Singh.
….Opposite parties.
QUORUM
JOT NARANJAN SINGH GILL: PRESIDENT
SARITA GARG ; MEMBER
KANWALJEET SINGH : MEMBER
For the complainant : Shri Jagmeet Singh Advocate
For the Op no.1 : Exparte
For the OPs no.2&3 : Complaint withdrawn.
ORDER
KANWALJEET SINGH, MEMBER
1. The complainant has alleged in this complaint that the complainant is a consumer qua the Ops. The complainant got himself and his family medically insured on the faith of agent of OP no.2. The Op no.1 issued policy document to the complainant having medical insurance coverage w.e.f. 09.07.2021 to 08.07.2023 bearing policy no.26-21-0007130-000. On 27.09.2022 the complainant got suffered from dengue and admitted in the hospital of OP no.3 and discharged on 01.10.2022. After that the complainant lodged claim with OP no.1 through OP no.2 but OP no.1 illegally repudiated the claim of the complainant on false ground. The complainant got served a legal notice dated 18.04.2023 to the OPs regarding to release the claim amount of Rs.25378/- alongwith interest but the OPs failed to do so. As such the OPs committed deficiency in service and unfair trade practice qua the complainant. The complainant lastly prayed that the Ops may kindly be directed to release the claim amount of Rs.25378/- alongwith interest @18% per annum from the date of admission in the hospital till realization and to pay Rs.50,000/- on account of mental agony and Rs.22000/- as litigation expenses.
2. Upon notices to the Op no.1, despite that OP no.1 neither appear nor contest the complaint as such OP no.1 was proceeded against exparte vide separate order dated 19.07.2023. As far as OPs no.2 and 3 are concerned, the complainant suffered a statement dated 30.05.2023 that he withdraw the complaint against OPs no.2&3.
3. To prove his complaint, the complainant tendered into evidence affidavit Ex.C-1 and some documents Ex.C-2 to Ex.C-10 and closed evidence.
4. We have heard the learned counsel for complainant and gone through the record file carefully with the valuable assistance of the learned counsel for the complainant. During exparte arguments the contentions of the counsel for complainant are similar to the respective pleadings, so there is no need to reiterate the same to avoid repetition.
5. Now, come to major controversy, whether the complainant is liable for relief as claimed by him in his prayer or not ?
6. It is not disputed that the complainant availed family health insurance from the OP no.1. During arguments, learned counsel for the complainant more forced on the document Ex.C-4 and stated that firstly OP no.1 granted the reimbursement of health insurance claim qua the complainant. It transpires from Ex.C-4 page no.2 that the OP no.1 has already been approved the amount of Rs.14417/- as reimbursement of medical treatment alongwith treatment receipts and also stated that the amount of Rs.10961/- to be paid by the insured. From the perusal Ex.C-4 page no.2 the claim detail mentioned the reason for deduction “ 2 days stay not justified” . However, on page no.3 of Ex.C-4 the claim amount Rs.25378/- was rejected by the OP no.1. Moreover, the complainant moved a representation dated 13.03.2023 to the OP no.2 which was duly received by OP no.2 and OP no.2 put his official stamp and representation receiving date 13.03.2023 regarding the share of complainant’s original policy, original bill and perfect reason for claim rejection. After that on 29.03.2023 the complainant sent a reminder to the OP no.2. Again the complainant sent a letter to the OP no.2 enquired about processing of the claim. Such letter was duly received by OP no.2 and embosses the official stamp and received the letter of the complainant.
7. To trace out the veracity of truth, “whether the complainant stayed for treatment in the hospital concerned for two days stay justified or not?
8. To solve this issue, we have minutely examined Ex.C-3 ( pages 1 to 26). bill dated 27.09.2022 of Rs.1350/-, dated 28.09.2022 bill of Rs.250/-, dated 30.09.2022 bill of Rs.650/-, dated 01.10.2022 bill of Rs.250/-, bill dated 27.09.2022 of Rs.1769/-, bill dated 30-.09.2022 of Rs.2147/- , bill dated 03.10.2022 of Rs.1212/- . The above said bills were issued by the Goel Laboratory & E.C.G. Centre, Opposite HDFC Bank, Dhuri Gate, Sangrur and Health HUB Pharma, Near Dr. Jagmohan Hospital, Dhuri Road, Sangrur. From the perusal of Ex.C-3 page no.5 it is specifically mentioned that the complainant admitted for treatment of Dengue fever in the hospital of Dr. Jagmohan Singh M.D.(Medicine) . Further, the complainant has produced hospitalization charges bill on page no.8 of Ex.C-3 with regard to indoor room charges 5X2000+10,000/- , Doctor’s visiting fee charges 5X500=2500/- an Nursing care charge 5X1000=Rs.5000/- Total Rs.17500/- . Such bill issued by the Doctor (supra) and he put his signatures alongwith stamp on the same. During the stay of the complainant for treatment in the hospital the investigation also conducted by the doctor since 27.09.2022 to 01.10.2022. During the treatment the doctor conducted the check up of the complainant like as B.P, temperature and noted daily progress of the complainant and other treatment such as drip, injection was given to the complainant by doctor. It is pertinent to mention here that the complainant also visited for follow up treatment and met to the doctor on 05.10.2022 and doctor mentioned on his description slip that the complainant is fit to join his duty. Furthermore, the Health Claim Questionnaire duly filled by the doctor concerned and mentioned that the complainant having symptoms of Dengue fever and stated that answers given by him are true to the best of his knowledge and doctor also embosses his stamp and put his signature on the questionnaire which was required by the OP no.1 for reimbursement of the health insurance claim of the complainant. From the perusal of document Ex.C-3 page no.1 to 26 the complainant lodged his claim to the OP no.1. It transpires from the perusal of Ex.C-3 each and every page the OP no.1 duly stamped of claim repudiated. From the perusal of Ex.C-3 page no.9 it is crystal clear that the complainant admitted on 27.09.2022 and discharged on 01.10.2022 meaning thereby the complainant admitted in the hospital for five days so the stand of OP no.1 as mentioned as per Ex.C-4 page no.2 “ 2 days stay not justified” is not a genuine and lawful ground by the OP no1 for repudiating the claim of the complainant. From the perusal of Ex.C-2 page 2 the policy in question is valid from 09.07.2021 to 08.07.2023, so the policy tenure was two years. The treatment of dengue fever of the complainant was occurred during the validity period of the health policy and the complainant paid the premium of Rs.6857/- as per page no.6 of Ex.C-2. Moreover, the complainant solemnly affirm and declare on oath through his affidavit in evidence which is Ex.C-1 that he was suffered from dengue and admitted in the hospital of OP no.3 on 27.09.2022 and discharged on 01.10.2022. As such, we have no hesitation to hold that the complainant has taken the treatment from 27.09.2022 to 01.10.2022 in Dr. Jagmohan’s hospital, Dhuri Road, Sangrur. “A man can lie, but document can’t”. This is a fit case to redress the grievance of the complainant.
9. Resultantly, keeping in view of the facts and circumstances of the complaint in hand and with careful analysis of the evidence available on record, we partly allow the complaint and direct the OP no.1 to pay the claim amount of Rs.25378/- alongwith interest @7% per annum from the date of filing the complaint i.e. 24.05.2023 till realization and further to pay to the complainant a consolidated amount of Rs.5000/- as compensation and litigation expenses. This order of ours shall be complied with by OP no.1 within 45 days from the date of receipt of copy of the order.
10. The complaint could not be decided within the statutory time period due to heavy pendency of cases.
11. Copy of this order be supplied to the parties free of cost. File be consigned to the records after its due compliance
Announced
March 11, 2024
( Kanwaljeet Singh) ( Sarita Garg) (Jot Naranjan Singh Gill)
Member Member President
BBS/-
