Haryana

Panchkula

CC/104/2020

MRS.POOJA CHANDOK. - Complainant(s)

Versus

APOLLO MUNISH HEALTH CARE. - Opp.Party(s)

SONIA SAINI.

30 Oct 2024

ORDER

            BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,  PANCHKULA

 

                                                       

Consumer Complaint No

:

104 of 2020

Date of Institution

:

28.02.2020

Date of Decision

:

30.10.2024

 

 

Mrs. Pooja Chandok wife of Sh. Puneet Chandok #121-A Housing Board, Kalka.

 

Second Address: #27 HIG Block number 11 Sector-4, Parwanoo Tehsil Kasauli, District Solan.

 

                                                                           ….Complainant

Versus

Apollo Munish Health Care having head office Central Processing Center 2nd & 3rd Floor plot number 404-405 Udhyog Vihar, Phase-3, Gurugram.          

                                                                                     ….Opposite Party

COMPLAINT UNDER SECTION 35 OF THE CONSUMER PROTECTION ACT, 2019

 

 

Before:              Sh.Satpal, President.

                        Dr.Sushma Garg, Member

                        Dr.Suman Singh, Member

                       

 

For the Parties:   Ms. Sonia Saini, Advocate for the complainant.  

                        Sh. Arjun Kundra, Advocate for OP.

                       

               

       

ORDER

(Satpal, President)

1.             The brief facts, as per  pleadings and documentary evidence placed on record by the parties, are, that a health care policy bearing no.120100/12586/2017/A009857 valid w.e.f. was purchased by the complainant from the Opposite party(hereinafter referred to as OP); on 30.05.2019, the complainant suffered knee injury in the road side accident, while she was travelling with her husband on the scooty; thereafter, she was taken to Raffels hospital, Sector-14, Panchkula, wherein she was found to have suffered AVULSIONCHIP FRAXTURE TALUS in right knee. The complainant was admitted in the said hospital i.e. raffels hospital, Panchkula on 30.05.2019 and discharged on the next day i.e. 31.05.2019; the expenses incurred during the hospitalization of the complainant were paid to the hospital by the complainant at her own level and thereafter, the claim having ID No. 1066277-UHID No.269652 was lodged with the OP seeking reimbursement of the expenses i.e. Rs. 22,210/- incurred during her treatment;  the OP vide letter dated 09.12.2019 repudiated the claim on the ground that there was no need of admission in the hospital even for one day. It is averred that the complainant was admitted on the advice of the expert opinion i.e. doctor and thus, the rejection of the genuine claim of the complainant by the OP was not valid and justified. Due to the act and conduct of the OPs, the complainant has suffered mental agony, harassment and financially; hence, the present complaint.

2.             Upon notice, the OP appeared through its counsel and filing written statement by raising preliminary objections that no cause of action has accrued in favour of the complainant against the OP and the present complaint is not maintainable in the present form; the complaint is barred by law of limitation acquiescence, estoppels and waiver; the complainant has suppressed the material facts. The complaint is liable to be dismissed on account of non-joinder and mis-joinder of necessary parties. It is submitted that complicated question of law and facts are  involved in the adjudication of the present complaint, wherein elaborate oral as well as documentary evidence would be required by way of examination and cross examination of the witnesses, which is not feasible under the summary procedure being followed in the Consumer Protection Act. It is submitted that A group assurance health plan was issued to Canara Bank, who was the master policy holder and who had enrolled the complainant as member under the said Group insurance policy as per terms and conditions. It is submitted that the insurance is a contract between two parties and both the parties are under the obligation to apply/comply and fulfill all the terms and conditions of the policy in strict sense of the  words written therein. It is submitted that a reimbursement claim was received from the complainant on 09.07.2019, who had got admitted herself in Raffels hospital, Panchkula for treatment of AVULSION CHIP FRACTURE TALUS with the date of admission i.e. 30.05.2019 and date of discharge on 31.05.2019 with claimed amount of Rs.22,210/-. It is submitted that the claim as lodged by the complainant was evaluated and it was found that admission of the complainant in the hospital was not required for the purposes of cast(plaster) treatment for her fracture. It is submitted that the plasting qua the fracture in the leg of the complainant could have been managed on out-patient basis. It is submitted that the complainant had failed to establish need for her hospitalization on account of the alleged accident and thus, the claim was repudiated as per terms and conditions of the policy vide repudiation letter dated 16.07.2020.

                On merits, the pleas and assertions made in the preliminary objections have been reiterated and it has been prayed that there is no deficiency in service on the part of the OP; as such, the present complaint is liable to be dismissed.

3.             To prove the case, the learned counsel for the complainant has tendered affidavit as Annexure C-A along with documents Annexure C-1 to C-18 in evidence and closed the evidence by making a separate statement. On the other hand, the learned counsel for the OP has tendered affidavit as Annexure R-A along with documents Annexure R-1 to R-3 in evidence and closed the evidence.

4.             We have heard the learned counsels for the complainant as well as OP and gone through the entire record available on the file including written argument filed by the OP, minutely and carefully.

5.             The learned counsel for the complainant, during arguments, reiterated the averments as made in the complaint as also in the affidavit(Annexure C-A) and contended that the claim bearing ID No.1066277 was lodged with the OP seeking the reimbursement of the expense incurred by the complainant during her hospitalization in Raffels Hospital, Panchkula w.e.f. 30.05.2019 to 31.05.2019 but the OP, acting in a deficient manner, has wrongly repudiated the claim vide letter dated 09.12.2019(Annexure R-3) on the ground that the hospitalization was not required qua the treatment of the complainant. It was argued that the complainant was hospitalized on 30.05.2019 in Raffels Hospital, Panchkula on the advice of treating Doctor and thus, the repudiation of the claim made by the OP was not valid and proper.

6.             On the other hand, the learned counsel on behalf of the OP while reiterating the averments as made in the written statement as also in Affidavit(Annexure R-A) contended that the hospitalization of the complainant in connection with her fracture was not required as the cast(plaster) treatment was possible on the OPD basis and thus, the repudiation of the claim was made on valid and proper grounds. It was argued that no expert advice is made available by the complainant on record, to prove that the hospitalization of the complainant was necessary for the treatment of her fracture; thus, the complaint is liable to be dismissed being frivolous, baseless and meritless.

7.             Undoubtedly, the claim bearing ID No. 1066277 was lodged by the complainant during the subsistence of the Group Assurance Health Plan(Annexure C-1/R-1). Further, the genuineness of the discharge summary(Annexure C-5) and the bills(Annexure C-6, C-7, C-10, C-11, C-13, C-14, C-14, C-15, C-16, C-17 & C-18) is not in dispute. The OP has repudiated the claim vide letter dated 16.07.2019(Annexure R-3) on the ground that the hospitalization of the complainant was not required.

8.             We have perused the discharge summary(Annexure C-5) and found that the complainant was diagnosed having “AVULSION CHIP FRACTURE TALUS” and she was explained Prognosis that there might be chances of infection and pain. The complainant was treated by Dr. Pardeep Aggarwal and as per discharge summary, she was hospitalized on 30.05.2019. In case, the OP had any doubt or suspicion qua the genuineness of the claim lodged by the complainant, it(OP) ought to have approached the said Dr.Pardeep Aggarwal in order to find  out whether  the hospitalization of the complainant was necessary or not. However, the OP had made no such efforts in order to falsify the claim of the complainant. In para no.5, the complainant has specifically averred that she was admitted on the advice of treating Doctor. The OP in para no.5 of the written statement has pleaded that repudiation was made after taking the expert opinion. However, we do not find any such expert opinion on record, which shows that the hospitalization of the complainant was not necessary. It is well settled legal proposition that mere bald assertions which are not corroborated and substantiated by any adequate, cogent and credible evidence do not carry any evidentiary value; thus, we are of the opinion that the repudiation of the claim by the OPs vide letter dated 16.07.2019(Annexure R-3) was not based on valid and justified grounds; thus, we hold the OP deficient while rendering services to the complainant, for which, it is liable to compensate the complainant.

9.             In relief, the complainant has claimed the reimbursement of an amount of Rs.22,210/- along with interest. Further, a compensation of Rs.2,00,000/- and Rs.2,00,000/- has been claimed on account of mental agony, harassment and litigation charges.

The details of the bills are given as under:-

Sr. No.

Cash memo/ draft/ bill dated

Amount (Rs.)

Annexure

1

07.06.2019

500

C-7

2

30.05.2019

6000

C-8

3

30.05.2019

9000

C-11

4

30.05.2019

1000

C-12

5

07.06.2019

1240

C-13

6

20.06.2019

2270

C-14

7

31.05.2019

1240

C-15

8

30.05.2019

700

C-16

9

20.06.2019

500

C-17

10

20.06.2019

1000

C-18

 

10.            As a sequel to the above discussion, we partly allow the present complaint with the following directions to the OP:-

  1. To refund the amount of Rs.22,210/- to the complainant along with interest @ 9% per annum (simple interest) w.e.f. 30.05.2019 i.e. the date of hospitalization of the complainant till its actual realization.
  2. To pay a compensation of Rs.5,000/- to the complainant on account of mental agony and harassment
  3. To pay an amount of Rs.5,000/- as litigation charges.

11.            The OP shall comply with the directions/order within a period of 45 days from the date of communication of copy of this order to OP failing which the complainant shall be at liberty to approach this Commission for initiation of proceedings under Section 71/72 of CP Act, against the OP. A copy of this order shall be forwarded, free of cost, to the parties to the complaint and file be consigned to record room after due compliance. 

 

Announced on: 30.10.2024

 

 

 

 

        Dr.Suman Singh            Dr.Sushma Garg                 Satpal

                Member                     Member                     President

 

Note: Each and every page of this order has been duly signed by me.

 

                                                   Satpal

                                             President

 

 

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