Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 329
Instituted on : 31.05.2022
Decided on : 04.03.2024
Gourav Kadian age 25 years s/o Sombir Singh R/o Village-Wazirpur, Teh-Beri, District Jhajjar at present H.No.D-98, Suncity, Sector 34, Rohtak.
……….………….Complainant.
Vs.
- Aditya Birla Health Insurance Co. Ltd., Regd. Office 9th Floor, Tower-1, One Indiabulls Centre, Jupiter Mills Compound, 841, Senapati Bapat Marg, Elphinstone Road, Mumbai-400013 through its Director.
- Axis Bank Ltd. Wazirpur, The.-Beri, Distt. Jhajjar through its Branch Manager-124201.
...........……Respondent/opposite party.
COMPLAINT U/S 35 OF CONSUMER PROTECTION ACT.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. TRIPTI PANNU, MEMBER.
DR. VIJENDER SINGH, MEMBER
Present: Sh.Jaikaran Khatri, Advocate for the complainant.
Sh.Kunal Juneja, Advocate for the opposite party No.1.
Opposite party No.2 already exparte.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case as per the complainant are that he is having a saving bank account with the opposite party No.2 and the opposite party No.2’s officials insisted the complainant to obtain health insurance policy from opposite party No.1. Complainant had obtained health insurance vide policy No.23-20-0032377-00 valid from 02.01.2021 to 01.01.2022. The complainant suffered from dengue fever and was got admitted in Hridaya Nilayam Heart, Lung & Vascular Institute, Rohtak for treatment on 13.12.2021 and was discharged on 21.12.2021 from the hospital. An amount of Rs.231324/- was spent on treatment and medicines of the complainant. The complainant intimated to the opposite party’s officials about his admission and after treatment, he submitted all the treatment papers and bills to the respondent no.2 and applied for insurance claim. But the opposite parties had repudiated the claim of the complainant on the basis of scrutiny of the documents. Complainant requested the opposite parties to pass the genuine claim and to reconsider the claim but to no effect. Hence this complaint and it is prayed that opposite party may kindly be directed to pay the claim amount of Rs.231324/- alongwith interest @ 18% p.a. from the date of admission of complainant in the hospital till its realisation and also to pay a sum of Rs.100000/- as compensation and Rs.25000/- as litigation expenses to the complainant.
2. After registration of complaint, notice was issued to the opposite party. Opposite party No.1 in its reply has submitted that they received claim from the complainant informing that he was hospitalized from 13.12.2021 to 12.12.2021(however as per complaint and documents the date is 21.12.2021) for treatment of Dengue haemorrhagic fever and claimed expenses incurred in the said treatment. The claim and documents were verified and was noted that there is discrepancies and lapses in the event of hospitalization of the complainant. As per patient he was semi-conscious at the time of admission but as per ICP patient was conscious at the time of admission. Patient showed his Google time line and it showed the said hospital location but it was also showing other locations and he was moving also continuously. As per patient BP, PR Checker, monitor was used during the treatment but as per the ICP and final bill it was not mentioned. As per patient urine test, ECG, and Echo was not done during the treatment but as per the lab reports it was done. As per patient and final bill physiotherapy was done during the treatment but as per the ICP no such notes are mentioned. It is submitted that the above discrepancies clearly points out that fraudulent claim was raised by the complainant therefore the claim of the complainant was rejected by the opposite parties as per Section G of the terms and conditions of the policy. All the other contents of the complaint were stated to be wrong and denied and opposite party prayed for dismissal of complaint with costs. However, none appeared on behalf of opposite party No.2 and after expiry of statutory period of 30 days, opposite party No.2 was proceeded against exparte vide order dated 18.07.2022 of this Commission.
3. Ld. counsel for complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C12 and closed his evidence on dated 30.05.2023. Ld. Counsel for opposite party has tendered affidavit Ex.RW1/A, documents Ex.R1 to Ex.R4 and closed his evidence on 19.01.2024.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. We have perused the documents placed on record by both the parties. Opposite party No.1 has repudiated the claim of the complainant vide its letter Ex.C11 on the ground that on scrutiny of documents it has been observed that verification of claim documents reveals that there are discrepancies and lapses noted in the event of hospitalisation. As per written statement and affidavit opposite party No.1 has submitted that the patient was semi conscious at the time of admission but as per ICP patient was conscious at the time of admission, the patient show his google time line and it showed the said hospital location but it was also showing other locations and he was moving also continuously. As per patient BP, PR Checker, monitor was used during the treatment but as per the ICP and final bill it was not mentioned. As per patient urine test, ECG, and Echo was not done during the treatment but as per the lab reports it was done. As per patient and final bill physiotherapy was done during the treatment but as per the ICP and no such notes are mentioned.
6. Regarding the discrepancy about showing other locations, it is observed that if the mobile of the patient was with his attendant or some other person, then it can show the other locations or movement. Regarding the non mentioning of BP, PR checker, monitor in the ICP and final bill it is observed that ICP was not prepared by the complainant himself, if some facts are not mentioned in the ICP the same is not the fault of complainant. One other ground is that as per patient some tests were not done during treatment but as per the lab reports it was done. In this regard it is observed that the doctors take some samples of the patient and the tests which are required for the treatment are done and sometimes patient does not know about it. Hence the claim is repudiated on flimsy grounds. It is not the plea of the opposite party that the bills submitted by the complainant are fake or the patient was not admitted in the hospital. But some false and fabricated grounds have been taken by the opposite party. Hence the repudiation of claim by the opposite party No.1 is on flimsy grounds and there is deficiency in service on the part of opposite party No.1.
7. In view of the facts and circumstances of the case we hereby allow the complaint and direct the opposite party no.1 to pay the amount of Rs.231324/-(Rupees two lac thirty one thousand three hundred and twenty four only) alongwith interest @ 9% p.a. from the date of filing the present complaint till its realisation and also to pay a sum of Rs.5000/-(Rupees five thousand only) as compensation on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.
8. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
04.03.2024.
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Nagender Singh Kadian, President
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Tripti Pannu, Member.
……………………………….
Vijender Singh, Member
