Order by:
Smt.Priti Malhotra, President
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 on the allegations that complainant has purchased a policy bearing no.OG-23-1225-8441-00000012 from Opposite Parties valid from 27.04.2022 to 26.04.2025. During the policy period, complainant suffered from brain tumor and he got admitted in Global Heart & Super Specialty Hospital for the period from 17.06.2022 to 27.06.2022. Further, he admitted in Medanta Hospital, Gurugram from 27.06.2022 to 02.07.2022. Thereafter complainant started treatment from Fortis Hospital, Gurugram from 11.08.2022 regarding radiation. The complainant has submitted all the relevant documents with the Opposite Parties for the reimbursement of the claim. But, the Opposite Parties have made a payment of Rs.3,00,000/- and refused to pay the remaining claim amount. Due to above said wrongful act on the part of the Opposite Parties, the complainant suffered mental agony as well as financial loss. Hence this complaint. Vide this complaint, the complainant has sought the following reliefs”-
a) Opposite Parties may be directed pay a sum of Rs.4,80,000/- alongwith interest thereon @ 24% per annum.
b) To pay an amount of R.1,00,000/- as compensation on account of mental tension and harassment caused to the complainant.
c) And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.
2. Opposite Parties appeared through counsel and contested the complaint by filing the written version taking preliminary objections therein inter alia that the complaint is not maintainable; the complainant has got no locus-standi; no deficiency in service has been attributed to the Opposite Parties and from the allegations in the complaint no deficiency in service is made out; the complaint is absolutely false and frivolous; complicated question of law and facts are involved in the present complaint. This Commission has got no jurisdiction to entertain, try and dispose of the complaint. Averred further that the complaint deserves dismissal; the complainant has not approached this Commission with clean hands rather he has willfully concealed the material and patent facts from this Commission while filing the present complaint which ipso-facto disentitles the complainant to seek any relief against the Opposite Parties. Further alleged that Opposite Parties have already paid an amount of Rs.94,934/- on dated 5th July, 2022 to Global Heart Super Specialty Hospital, Rs.2,05,066/- on dated 19th July 2022 to Global Heart Super Specialty Hospital, Rs.60,000/- on 15th September, 2022 to complainant and Rs.1,40,000/- on 31st October, 2022 to complainant. Complaint is absolutely false and frivolous. Therefore, the present complaint is liable to be dismissed. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.
3. Complainant also filed replication to the written reply of Opposite Parties denying the objections raised by Opposite Parties in its written reply.
4. In order to prove his case, complainant tendered in evidence his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C11.
5. To rebut the evidence of complainant, Opposite Parties tendered in evidence affidavit of Sh.Saurav Khullar, Authorized Signatory, Bajaj Allianz General Insurance Co. Ltd. Ex.OPs1 alongwith copies of documents Ex.OPs2 to Ex.OPs7 and additional affidavit of Sh.Saurav Khullar, Authorized Signatory Ex.OPs8.
6. We have heard the counsel for the parties and also gone through the documents placed on record.
7. The purchase of the mediclaim policy by the complainant for the period from 27.04.2022 to 26.04.202 and during the policy coverage the complainant suffered from brain tumor and for the treatment of the same, he admitted in Global Heart & Super Specialty Hospital, Medanta Hospital, Gurugram and Fortis Hospital, Gurugram are not disputed facts and are duly proved on record. During the hospitalization in the aforesaid hospitals, the complainant spent an amount of Rs.1,31,697/-, Rs.4,21,761/- and Rs.3,43,380/- respectively, copies of the bills are placed on record Ex.C3, Ex.C5 and attached with Ex.C-6. It is gathered from the record that against the claimed amount which the complainant claimed to be incurred on the treatment undertaken in the hospital, the Opposite Parties admittedly paid the amount as per sum insured under the policy, which the Opposite Parties claimed to be Rs.5,00,000/-.
8. It is also duly been admitted by the complainant i.e. in para no.8 of the complaint that the Opposite Parties have paid Rs.3 lakh and vide separate statement dated 15.05.2023, ld. Counsel for the complainant further admitted that the claim amount of Rs.2,00,000/- more has been received from the Opposite Parties.
9. Ld. Counsel for the complainant vide above stated suffered statement dated 15.05.2023 claimed for the remaining amount of Rs.2,80,000/-. In our considered opinion, the said amount of Rs.2,80,000/- is not payable or due to be paid by the Opposite Parties as the perusal of the policy document Ex.C2 clearly reveals that sum insured of the complainant under the policy is Rs.5,00,000/- and the Opposite Parties with due proof on record have paid the amount which has been raised vide respective bills as per the sum insured under the policy in question to the hospitals concerned.
10. During the course of arguments, ld. Counsel for the complainant further argued that the complainant is also entitled for 56% cumulative bonus, whereas there is no averment in the complaint itself and also as per the policy terms and conditions, the same is available only when there is no claim raised in the previous policy period and also no reasonable justification and clarification been given by the counsel for the complainant to establish the same. Since, the sum insured under the policy is duly been paid against the claim/bills raised by the complainant, so nothing more is found to be due on the part of the Opposite Parties in the present complaint. Hence, no deficiency in service is made out on the part of Opposite Parties.
11. In view of the discussion above, we hereby dismissed the complaint of the complainant. However, keeping in view the peculiar circumstances of the case, the parties are left to bear their own costs. Copies of the order be furnished to the parties free of cost. File be consigned to record room after compliance.
Announced on Open Commission
