Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 477.
Instituted on : 4.10.2018.
Decided on : 15.02.2021.
Nikhil Jain son of Shri Vijender Kumar Jain, resident of H.No.1396, Sonepat Road, Near Sky Tech Mall, Sector-3, Rohtak.
………..Complainant.
Vs.
- Aditya Birla Health Insurance Co. Ltd., 10th Floor, R-Tech Park, Nirlon Compound, Next to HUB Mall off. Western Express Highway, Goregaon East, Mumbai-400063 through its Branch Manager/ concerned Officer.
- Aditya Birla Health Insurance Co. Ltd., Unit No.1 & 2, 1st Floor, Parmesh Corporate Tower, Plot No.13, Karkkardooma Community Centre, New Delhi-110001 through its Branch Manager.
- Smt. Rekha Jain agent, Intermediary Code ABH1100302, Aditya Birla Health Insurance Co. Ltd., Unit No.1 & 2, 1st Floor, Parmesh Corporate Tower, Plot No.13, Karkkardooma Community Centre, New Delhi-110001.
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
MS. TRIPTI PANNU, MEMBER.
DR. RENU CHAUDHARY, MEMBER.
Present: Sh. NK Suhag, Advocate for the complainant.
Sh. Kunal Juneja, Advocate for opposite parties.
ORDER
RENU CHAUDHARY, MEMBER:
1. Brief facts of the case are that complainant obtained a Health Insurance Policy for himself as well as his family including his minor son Agam Jain bearing No.11-17-0004338-00 having plan name Active Health Platinum-enhanced for a period of one year commencing from 31.8.2017 to 30.8.2018 from opposite party no.3. On 31.1.2018, the son of the complainant suffered from lower respiratory track infection and thus, he took his son at Sanghi Nursing Home, Rohtak and the concerned Dr.Anil Sanghi admitted his son on the same day for his treatment. In this regard, he gave telephonically intimation to the opposite party no.3 and on the toll free no.1800 1031033 of the opposite party no.1. The son of the complainant had been admitted in Sanghi Nursing Home w.e.f. 31.01.2018 to 05.02.2018 and he paid an amount of Rs.20053/- for the treatment of his son namely, Aagam Jain. Thereafter, he submitted claim form alongwith relevant documents vide claim registration No.1121710001046 through courier with the opposite party no.2 and requested to pass the aforesaid claim. Thereafter, on 10.04.2018, he received an e-mail from Dr. Jimeet Jain, being HOD claims of opposite party no.1, rejected the claim of the complainant on the ground that : “On scrutiny of the document it has been observed that the claims is not admissible as per the below mentioned clauses fraudulent claim”. The complainant requested the opposite parties to make reimbursement of the amount spent by him on the treatment of his son but the opposite parties did not pay any heed to the requests of complainant. On 6.8.2018, the complainant got received a letter from Kamini Shahani being Head Customer Service of opposite party no.1 and the opposite party no.1 mentioned in the aforesaid letter Clause No.5 and in terms of the above clause, the premium amount paid towards this policy has been forfeited and there will be no refund on account of cancellation of the policy. The complainant also served a legal notice dated 29.8.2018 through his counsel to the opposite parties but they did not submit any necessary reply. Hence this complaint and the complainant has prayed for directing the opposite parties to pay an amount of Rs.25103/-(amount of policy premium)+Rs.20053/-(treatment expenses) alongwith interest @ 24% p.a. from 5.2.2018 till actual its realization and also to pay an amount of Rs.1,00,000/- on account of harassment and Rs.25,000/- as litigation expenses to the complainant.
2. After registration of complaint, notices were issued to the opposite parties. Opposite parties in their reply has submitted that during investigation, it was found that the insured being the son of the complainant was not hospitalized in Sanghi Nursing Home for treatment but was operated on OPD basis and hence, the hospitalization bills submitted by the complainant were false and forged. It is also submitted that the complainant never contacted the opposite parties over call intimating about the treatment or admission of the insured into the hospital. It is also submitted that there is discrepancy in the date of discharge and hence, the claim of the complainant cannot be processed unless the treatment expenses are proved as genuine beyond doubt. The repudiation of claim was in accordance with 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.
3. Ld. Counsel for the complainant in his evidence has tendered affidavits Ex.CW1/A to Ex.CW1/C, documents Ex.C1 to Ex.C18 and has closed his evidence on dated 31.5.2019. On the other hand, ld. counsel for the OPs has tendered affidavit Ex.RW1/A and documents Ex.R1 to Ex.R6 and has closed his evidence on dated 22.12.2020.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. The claim of the complainant has been repudiated by the opposite party on the ground that hospitalization bills submitted by the complainant were false and forged. During investigation, it came to know that there is discrepancy in the hospital bill, which was submitted at the time of claim. Moreover the reports of the lab test which have been submitted by the complainant, has not been signed by Dr. R.K.Bhatnagar and further submitted that Dr. Dr.R.K..Bhatnagar had not conducted any pathological test at Sanghi Nursing Home. In this way the reports as well as bills submitted by the complainant are false and fake. We have perused documents Ex.CW1/B of Dr.Anil Sanghi. In this affidavit it has been deposed by Dr. Anil Sanghi that the hospital charged an amount of Rs.18978/- on account of lab charges, medicine charges and hospital charges. The main grievance of the insurance company is that the lab reports which have been submitted by the complainant with the insurance company are found false and fabricated because a written note has been issued/submitted with Aditya Birla Health Insurance Company by Dr. R.K.(Rakesh Bhatnagar) with the submissions that he has not conducted any pathological lab test at Sanghi Nursing Home. All the report of the patient Master Agham were not belonged to him and pathological test have not done by him at any time or under his supervision and the same are false and fake one. On the other hand, as per affidavit Ex.CW1/B, complainant had spent an amount of Rs.18978/- on account of hospital bill. Hence the complainant is entitled for the alleged amount after deduction of Rs.480/- on account of lab charges.
6. In view of the facts and circumstances of the case we hereby allow the complaint and direct the opposite party No.1 & 2 to pay the amount of Rs.18498/-(Rupees eighteen thousand four hundred and ninety eight only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e.04.10.2018 till its realization and shall also 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.
7. 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:
15.02.2021.
................................................
Nagender Singh Kadian, President
..........................................
Tripti Pannu, Member.
……………………………….
Renu Chaudhary, Member.
