Order by:

Sh.Amrinder Singh Sidhu, President

The  complainant  has filed the instant complaint under section 35 of Consumer Protection Act, 2019 on the allegations that  the complainant had purchased a health insurance policy bearing No.P/211222/01/2021/000724 from Opposite Parties 1 and 3 through Opposite Party No.2 against the paid up premiums. Further alleges that the complainant unfortunately fallen on the floor and due to the said accident, the neck of femour bone fractured and was admitted in Goyal Hospital, Moga on 18.04.2021 where the complainant remained admitted till 22.04.2021 and got operated . After the treatment, the complainant lodged the claim for the reimbursement of her claim for Rs.1,15,515/- with the Opposite Parties and completed all the formalities, but the Opposite Parties rejected the claim of the complainant on the false and frivolous grounds that the falls in the category of joint replacement surgery which must has waiting period of 2 years and the Opposite Party No.1 is unable to approve the claim, but said ground is not legal and genuine. At the time of selling the policy in question, the Opposite Parties had misguided the complainant and now making excuses after one or the other instead of reimbursement of the claim to the complainant.   The repeated requests have been made by the complainant to the opposite parties to reimburse the medical expenses and not compel the complainant to indulge into any litigation, but the opposite parties refused to admit the rightful claim of the complainant. Vide instant complaint, the complainant has sought the following reliefs.

a)       Opposite Parties may be directed to compensate the complainant  with Rs.1,15,515/- and also to pay  Rs.2,00,000/- be allowed to be paid by the opposite parties on account of compensation due to mental tension and harassment caused by the complainant besides Rs.20,000/- as travel expenses.

b)      The cost of complaint amounting to Rs.25,000/- may please be allowed.

c)       And any other relief to which this Hon’ble Consumer Commission, Moga may deem fit be granted in the interest of justice and equity. 

Hence this complaint has been filed by the Complainant for the redressal of her grievances.

2.       Upon notice, none has appeared on behalf of Opposite Parties 1 and 3  despite service, hence Opposite Parties No.1 and 3 were proceeded against exparte. 

3.       Opposite Party No.2 appeared through their counsel and filed the reply taking the preliminary objections inter alia and alleged that the complainant has made the answering Opposite Party unnecessarily. The answering Opposite Party  has neither provided any loan to the complainant nor collected/ recovered any amount from the complainant as alleged. The complainant had claimed relief’s only against Opposite Parties No.2 and 3 from where the complainant had availed the health insurance and Opposite Party No.2 is not a necessary party to the said complaint. The complainant’s main dispute is with respect o the rejection of the health insurance claim and the rejection or acceptance of any claim is in the hands of Opposite Parties No.1 and 3 and the answering Opposite Party No.2 has nothing to do with the claim.  The Opposite Party No.2 is a mere financier providing loans to the needy people and has no role to play in the acceptance or rejection of the insurance claim and hence, the instant complaint against Opposite Party No.2 ought to be dismissed. On merits, Opposite Party No.2 took up almost the same and similar pleas as taken up by them in the preliminary objections and hence it is prayed to dismiss the complaint against answering Opposite Party being not maintainable.         

4.       In order to prove her case, the complainant tendered into evidence her affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C44 and closed the evidence.    

5.       On the other hand, Opposite Party No.2 also tendered into evidence the affidavit of Ms.Shavani Garg, Ex.R1/A alongwith copies of documents Ex.R1 to Ex.R3 and closed the evidence on behalf of Opposite Party No.2.  

6.       We have heard the ld.counsel for the Complainant as well as ld.counsel for Opposite Party No.2 and have carefully gone through the evidence on record.

7.       During the course of arguments, ld.counsel for the Complainant as well as ld.counsel for Opposite Party No.2   have mainly reiterated the facts as narrated in the complaint as well as in the written statement respectively. We have perused the rival contentions of  the parties and also gone through the record on file. The main contention of the complainant is that she had purchased a health insurance policy bearing No.P/211222/01/2021/000724 from Opposite Parties 1 and 3 through Opposite Party No.2 against the paid up premiums. Further alleges that the complainant unfortunately fallen on the floor and due to the said accident, the neck of femour bone fractured and was admitted in Goyal Hospital, Moga on 18.04.2021 where the complainant remained admitted till 22.04.2021 and got operated . After the treatment, the complainant lodged the claim for the reimbursement of her claim for Rs.1,15,515/- with the Opposite Parties and completed all the formalities, but the Opposite Parties rejected the claim of the complainant on the false and frivolous grounds that the falls in the category of joint replacement surgery which must has waiting period of 2 years and the Opposite Party No.1 is unable to approve the claim, but said ground is not legal and genuine. At the time of selling the policy in question, the Opposite Parties had misguided the complainant and now making excuses after one o the other instead of reimbursement of the claim to the complainant.   To corroborate her aforesaid assertion, the Complainant has placed on record her duly sworn affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C44. Not only this, with regard to loss incurred due to non payment of the medical expenses, the complainant  has sought compensation to the tune of Rs.2,00,000/-on account of mental tension and harassment  caused in the hands of the Opposite Parties  and cited judgement of Hon’ble Supreme Court of India titled as Patel Roadways Ltd. Vs. Birla Yamaha Ltd. III (2000) SLT 554-II (2000), CLT 83 (SC), 1(2000) CPJ 42 (SC) 2000 (4) SCC, 91.  The aforesaid evidence produced by the complainant has gone unrebutted and unchallenged through any cogent and convincing evidence on record as the Opposite Parties No.1 and 3   did not opt to appear and contest the proceedings.  In this way, the Opposite Parties  No.1 and 3 have impliedly admitted the correctness of the allegations made in the complaint. It also shows that Opposite Parties No.1 and 3   have no defence to offer or defend the complaint. Whereas, we are of the view that there is no role to play of Opposite Party No.2 as Opposite Party No.2 is only just a financer and they have nothing to do with the acceptance or rejection of the medical claim of the claimant.     

8.       So, from the entire unrebutted and unchallenged  evidence produced by the complainant on record, it stands fully proved on record that  the Opposite Parties No.1 and 3 have adopted unfair trade practice and deficiency in service by not making the medical reimbursement to the complainant.  On this count, the Complainant prayed for medical reimbursement as well as to  pay Rs.2,00,000/-as compensation for causing her mental tension and harassment and Rs.25,000/- as costs of litigation, but we are of the view that the claim for compensation to the tune of Rs.2,00,000/- appears to be exorbitant and excessive. The rationale behind grant of compensation has been to compensate a party of the loss occasioned by it. It is none of the intention of the legislature while legislating the Consumer Protection Act to enrich a particular party at the cost of the other. The compensation has to be awarded in commensuration with the loss occasioned to the complainant. In our considered view, ends of justice would  be fully met if the complainant is awarded lump-sum compensation to the tune of Rs.10,000/- and we award the same accordingly.

9.       In view of the aforesaid facts and circumstances of the case, we allow the complaint of the complainant against the Opposite Parties  No.1 and 3-Adity Birla Health  and Opposite Parties No.1 and 3-Aditya Birla Health  are directed to make the payment of Rs.1,15,515/- (Rupees one lakh fifteen thousands five hundred fifteen only) alongwith interest @ 8% per annum from the date of  filing the present complaint i.e. 01.02.2022 its actual realization.  Opposite Parties No. 1 and 3  are also directed to pay Rs.10,000/- (Rupees ten thousands only)  as lumpsum compensation to the complainant. However, the complaint against Opposite Party No.2-Finance stands dismissed.  Compliance of this order be made by the Opposite Parties No.1 and 3- Aditya Birla Health within 60 days from the date of receipt of the copy of this order, failing which the Complainant shall be at liberty to  get the order enforced through the indulgence of this Commission.   Copies of the orders be furnished to the parties free of cost. File is ordered to be consigned to the record room.  

Announced in Open Commission.

Dated: 16.08.2022.