PRESENT
Complainant by Adv.Aneesa resent.
Opponent by Adv. Bhawana Bhatt present.
ORDER
(Per- Mr. S. D. MADAKE, Hon’ble President.)
1. The complainant is a company and complainant no.2 is employee of the said company since 1988. The company has taken group medi-claim policy from opponent insurance company, for a period between 30/01/2010 to 29/01/2011 covering 563 employees and their dependents, including S.V.S. Deepak.
2. According to complainants, the policy was for a sum of Rs.two crorers and fifty nine lacs and premium was Rs.19,95,000/- which was paid by two cheques of Rs.12,45,000/- and Rs.7,50,000/- dated 28/01/2010. The said policy covered the employees, their wives and children.
3 The complainant no.2 who was the beneficiary of the policy, was admitted in Yashoda Hospital during 03/02/2010 and 08/02/2010 for treatment for myocardial infraction alongwith a mild dysfunction in the left ventricle of the heart. He spent Rs.2,64,810/-
(Rupees two lakh sixty four thousand eight hundred ten only) for treatment. He was again admitted in the hospital during 15/02/2010 to 18/02/2010.
4. The complainant no.2 filed the health insurance claim with relevant documents in March-2010 for reimbursement of the expenses. The insurance company credited an amount of Rs.1,31,929/-after repeated demands and rejected claim to the extent of Rs.1,53,988/- due to non-submission of necessary invoices.
5. The complainant no.2 submitted all documents on 13/10/2010 and repeatedly requested to opposite party for payments as per insurance contract,but there was no response, except false assurances.
6. The complainant no.2 has incurred expenses from the life savings and he was subjected to mental harassment due to deficiency in service by insurance company. He prayed for the direction to insurance company to pay Rs.1,53,000/- with interest as well as compensation of Rs.1,35,000/- and costs of Rs.60,000/-.
7. The opposite party filed written statement and submitted that complainant is frivolous and vexatious in nature and is liable to be dismissed with costs. It is submitted that complainants have failed to produce relevant documents, namely bills, vouchers or sticker for stent charges or required break-up of pharmacy.
8. The opposite party denied that complainant no.2 personally incurred total expenditure as alleged. It is denied that complainant submitted necessary documents on 13/11/2010 and informed on 14/01/2011. There is no deficiency in service as alleged by complainants.
9. The complainants produced on record medi-claim policy, discharge summary, coronary Anjiogram and PTCA reports, claim form, copies of mails etc. The opposite party filed on record policy and copy of letter dated 28/05/2011.
10. We have perused all documents produced on record as well as well as written notes of argument filed by both parties. Heard both parties at length. Admittedly, complainant no.1 has taken insurance policy by paying Rs19,95,000/- to opponent for a period 30/01/2010 to 29/01/2011. The complainant no.1 insured all 563 employees including Mr.Deepak for a sum of Rs.25,90,000/-.
11. The record shows that complainant claimed Rs.1,60,332/- towards pharmacy charges and opponent disallowed Rs.1,53,000/- on the ground of invoices, sticker for stent charges. The opponent also denied radiology charges of Rs.338/- and non-medical charges and miscellaneous charges of Rs.650/-.
12. The learned advocate for opposite party Bhavna Bhatt submitted that as per policy clause-5.5, the insured has to furnish original bills for the purpose of making claim, as per Sec.51 r/w.s.54 of Contract Act. She argued that as per S.5.64 of Evidence Act,1872 the complainant was required to produce documentary evidence or in absence of that, to produce secondary evidence as explained in S.65 of the Evidence Act, 1872 .
13. The learned advocate for complainant Aneesa Cheema argued that complainant has produced on record stent sticker and forwarded to opponent on 13/11/2010 and also filed on record details of expenses incurred towards pharmacy charges issued by hospital in addition to all tests reports.
14. We have carefully perused the documents relating to expenses incurred by complainant no.2 who was taking treatment in Yashoda Hospital in February-2010. It is not disputed that Deepak was the beneficiary of the policy. The details of the bills incurred by the complainant no.2 are on record.
15. The receipt issued by Yashoda hospital dt. 05/02/2010 shows that Deepak paid by cash Rs.2,45,000/- as deposit, receipt for Rs.20,000/-, receipt dt 15/02/2010, Rs.30,000/- receipt dt.18/02/2010, Rs.10,000/-. The bills produced on record relates to the treatment taken by Shri.Deepak in February-2010.
16. In the present case the only issue raised by opposite party was regarding sticker for stent and break-up of pharmacy for Rs.1,30,000/- and Rs.23,000/- respectively. We are of the view that complainant has filed on record sufficient evidence to show that complainant incurred income about treatment.
17. The complainant no.2 is entitled to claim the said amount with interest at the rate of Rs.9% p.a. from the date of repudiation of claim. The quantum of interest is awarded by way of compensation. The complainant no.2 is entitled for costs of Rs.10,000/-.
18. In the result, we pass the following order.
Order
RBT Complaint Case No. 534/2011 is partly allowed.
2. The Bajaj Allianz General Insurance Com.Ltd is ordered to pay
Rs.1,53,000/- with interest at the rate of Rs.9% p.a. from
28/05/2010 till realization of total amount to the complainant
no.2.
3. The opposite party is ordered to pay Rs.10,000/- as costs to
complainant.
4. Copy of this order be sent to both parties.
