BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 117 of 2021
Date of Institution : 21.06.2021
Date of Decision : 24.04.2024
Pargat Singh, aged about 35 years son of Sh. Harbhajan Lal, resident of village Rori, Tehsil and District Sirsa.
……Complainant.
Versus.
Aditya Birla Health Insurance Company Limited, 10th Floor, R-Tech Park, Nirlon Compound, Goregaon- East, Mumbai- 400063 through its Officer Incharge/ Authorized Signatory.
…….Opposite Party.
Complaint under the provisions of the Consumer Protection Act.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
SMT.SUKHDEEP KAUR……………MEMBER.
Present: Sh. Davinder Dandiwal, Advocate for the complainant.
Sh. Puneet Narang, Advocate for opposite party.
ORDER
The complainant has filed the present complaint under the provisions of the Consumer Protection Act against the opposite party (hereinafter referred as Op).
2. In brief, the case of complainant is that complainant had purchased health insurance policy i.e. plan Group Active Secure – Personal Accident from op for a period of one year i.e. w.e.f. 09.09.2020 to 08.09.2021 start date 01.12.2020 and end date 30.11.2021 for the insured amount of Rs.10,00,000/- which included risk of accidental death, permanent total disablement, permanent partial disablement etc. That unfortunately complainant met with an accident and suffered pain, swelling in left knee and feeling difficulty in walking following fall road side personal accident and accordingly he was got admitted in Guardian Hospital, Jalandhar on 20.01.2021 and remained admitted up to 23.01.2021. During the treatment, the doctors diagnosed ACL retear with degenerative tear posterior horn medical meniscus with 4 cm x 1.5 cm. chondral defect distal femur medical condylfrleft. That hospital authorities charged the amount of Rs.53,630/- vide final bill no. 1031 dated 23.01.2021 and he also paid lab charges to the tune of Rs.1630/- and an amount of Rs.42,500/- was paid by him on account of surgical system vide invoice dated 20.1.2021. It is further averred that complainant had informed the op regarding suffering of injuries due to personal accident and also requested for making payment of the aforesaid amount of bills and also submitted all the requisite documents but the company authorities avoided payment of claim amount with malafide intention. The op has neither accepted the claim nor rejected the same and has caused deficiency in service and unnecessary harassment to the complainant. Hence, this complaint.
3. On notice, op appeared and filed written statement submitting therein that op till date has not received any claim intimation/ documents regarding his alleged hospitalization or treatment. The complainant has not submitted any document, bills, discharge summary or medical reports relating to his alleged treatment. Therefore, the alleged claim has neither been accepted nor been rejected by the op and thus present complaint is a pre-mature complaint and is liable to be rejected out-rightly. It is further submitted that answering op is under no liability to pay any amount to the complainant. The op has a right to investigate the claim and documents related to the claims of the policy holder. As per terms and conditions of policy, claim form A and B, indoor case papers, discharge summary, medical treatment papers, KYC documents and bank details are required to be submitted at the time of making a claim which are essential for processing and settling the claim of the policy holder. After receiving the above mentioned documents, the claim and the documents will be scrutinized and then the op will decide whether or not to admit the claim. It is further submitted that complainant has jumped the entire process and has directly approached this Commission without providing any opportunity to the op to decide the claim and prayer for dismissal of complaint made.
4. The complainant in evidence has tendered his affidavit Ex. CW1/A and documents Ex.C1 to Ex.C8.
5. On the other hand, op has tendered affidavit of Sh. Richard Herish, Deputy Chief Manager as Ex.R1 and certificate of insurance Ex.R2.
6. We have heard learned counsel for the parties and have gone through the case file. Written arguments submitted on behalf of op have also been gone through by us in which the contents of written version are reiterated.
7. Admittedly the complainant had purchased health insurance plan from op for the period 09.09.2020 to 08.09.2021 with start date 01.12.2020 and end date 30.11.2021 for the sum insured amount of Rs.10,00,000/- as is evident from certificate of insurance Ex.C1. It is also proved on record that during the period of policy in question, complainant took treatment from Guardian Hospital, Jalandhar due to road side personal accident and he remained admitted in the said hospital from 20.01.2021 to 23.01.2021 and has claimed that he has spent total amount of Rs.97,750/- on his treatment. However, the claim of complainant has not been settled and paid by op on the ground that till date no claim with requisite documents have been submitted by complainant and according to op his claim has not been rejected or accepted so far for want of above said documents. On the other hand, complainant in his affidavit Ex. CW1/A has testified that op company in its written statement has concealed and misstated the true and material facts in order to avoid its liability for payment of insurance claim amount and all the concerned documents including bills and reports of the doctors etc. had been given and handed over to Shri Gurchet Brar insurance agent of op’s company through whats app and said authorized agent had sent those documents to the op company through email. He has further testified that now these are being produced by complainant in evidence. It is also strange and not believable that claimant who has spent huge amount on his treatment will not submit the documents despite the fact that he is having health insurance policy after paying premium and it seems that op in order to avoid its legal liability has taken such vague and false plea. Moreover, all the documents required for settlement of claim have been produced on record by complainant and it is also proved on record from bills Ex.C4 to Ex.C6 that complainant has spent total amount of Rs.97,750/- on his treatment and is entitled for reimbursement of said amount from op.
8. In view of our above discussion, we allow the present complaint and direct the opposite party to make reimbursement of the claim amount of Rs.97,750/- alongwith interest at the rate of @6% per annum from the date of filing of present complaint i.e. 21.06.2021 till actual payment within a period of 45 days from the date of receipt of copy of this order. We also direct the op to further pay a sum of Rs.10,000/- as compensation for harassment and Rs.5000/- as litigation expenses to the complainant within above stipulated period. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced. Member President,
Dated: 24.04.2024. District Consumer Disputes
Redressal Commission, Sirsa.
