Chandigarh

DF-I

CC/109/2022

Seema Tiwari - Complainant(s)

Versus

Bajaj Allianz General Insurance Co. Ltd. - Opp.Party(s)

Paras Sharma

02 Feb 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                                     

Consumer Complaint No.	:	CC/109/2022
Date of Institution	:	20/01/2022
Date of Decision	:	02/02/2024

 

Seema Tiwari wife of Sh. Chhinderpal Tiwari through her legal heirs :-

1. Chhinder Pal Tiwari husband of late Smt. Seema Tiwari and s/o Sh. Kasturi Lal r/o House No.425, Ward No.19, New Cantt. Road, Faridkot, Punjab.
2. Smiksha Tiwari daughter of Sh. Chhinder Tiwari r/o House No.425, Ward No.19, New Cantt. Road, Faridkot, Punjab.
3. Sagar Tiwari son of Sh. Chhinder Tiwari r/o House No.425, Ward No.19, New Cantt. Road, District Faridkot.

… Complainants

V E R S U S

Bajaj Allianz General Insurance Company Limited, 2^nd Floor, Satnam Complex, BMC Chowk, GT Road, Jalandhar, Punjab.

… Opposite Party

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Sh. Gaurav Kant Goel, Advocate for complainants
	:	Sh. Punit Jain, Advocate for OP

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Seema Tiwari (since deceased) through her legal heirs, complainants against the aforesaid opposite party (hereinafter referred to as the OP).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that on 25.6.2019, on the advice of the agent of the OP, the husband of the complainant had purchased a “Health Guard (Floater) Policy” for himself and his wife (i.e. the complainant) from the OP by paying gross premium of ₹29,981/- and the same was valid w.e.f. 2.7.2019 to 1.7.2020 and both were insured with 100% entitlement of policy claim with respect to the sum insured of ₹3.00 lacs. The aforesaid policy was further renewed w.e.f. 2.7.2020 to 1.7.2021 (hereinafter referred to as “subject policy”) on payment of premium of ₹31,000/-.  The complainant was under treatment from 5.2.2020 to 26.8.2020 at different places and all the bills (Annexure C-2) related to the treatment, including medicines and other miscellaneous expenses, were shared with the OP from time to time.  Many times, after scrutiny of the documents, the OP assured the complainant that the policy amount would be disbursed within a month, but, nothing has been done by the OP.  The complainant repeatedly requested the OP for the settlement of the claim raised by her, but, out of the total amount of ₹1,91,689/-, OP had only reimbursed an amount of ₹17,683/-. Copy of the Whatsapp chat with the agent of the OP is Annexure C-3.  Later on, the complainant came to know that, in fact, OP had rejected the partial claim of the complainant on the basis of clause 2(2) of the plan which only covers the expenses incurred during 60 days immediately before hospitalisation of the insured. In this manner, the aforesaid act of the OP amounts to deficiency in service and unfair trade practice. OP was requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OP resisted the consumer complaint and filed its written version, inter alia, taking preliminary objections of maintainability, concealment of facts and jurisdiction. It is alleged that, in fact, the complainant was explained the reasons of disallowance of the partial claim vide letter dated 10.3.2022 (Ex.OP-2) as pre-hospitalisation expenses incurred before 60 days of hospitalisation period were not payable as per condition No.3 of Section A Coverage of Health Guard Policy.  As it has come on record that the complainant was admitted in hospital/hospitalised on 22.7.2020 and discharged on 27.7.2020, as per the aforesaid clause of the policy, whatever bills coming within 60 days prior to admission in the hospital were paid to the complainant by the OP and rest of the bills were declined.  Even admission charges as well as diet charges and other bills pertaining to masks, gloves etc. were not payable to the complainant and the same were also declined as per terms and conditions of the policy.  In fact, the complainant had lodged claim of ₹1,59,829/- and the claim which was admissible as per terms and conditions of the subject policy to the tune of ₹17,683/- was paid to the complainant.  On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. Despite grant of sufficient opportunity, rejoinder was not filed by the complainant to rebut the stand of the OP.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully, including the written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the subject policy (Annexure OP-1) was valid w.e.f. 2.7.2020 to 1.7.2021 with sum insured of ₹3.00 lacs and claim for in-patient hospitalisation treatment w.e.f. 22.7.2020 to 27.7.2020 was filed by complainant, as is also evident from copy of claim form (Ex. OP-4) and the OP has partially allowed the claim of the complainant to the tune of ₹17,683/- whereas has denied the remaining claim of the complainant, the case is reduced to a narrow compass as it is to be determined the OP is unjustified in partially repudiating the genuine claim of the complainant and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the OP has rightly partially repudiated the claim of the complainant and the consumer complaint of the complainant, being false and frivolous is liable to be dismissed, as is the defence of the OP.
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms and conditions of the subject policy, medical record and repudiation letter and the same are required to be scanned carefully in order to determine the real controversy between the parties.
   3. Perusal of the terms and conditions of the subject policy (Annexure C-1/OP-1) clearly indicates that the same covers in-patient hospitalisation treatment with sum insured of ₹3.00 lacs. It is also clear from the terms and conditions of the subject policy that the in-patient hospitalisation treatment further covers the medical expenses for pre-hospitalisation and post-hospitalisation for specific period i.e. pre-hospitalisation expenses during 60 days immediately before the hospitalisation and 90 days immediately after the insured was discharged post hospitalisation. The relevant portion of the coverage is reproduced below for ready reference :-

“SECTION A) COVERAGE

1.     xxx                   xxx                   xxx

        2.     Pre-Hospitalization

        The Medical Expenses incurred during the 60 days immediately before You were Hospitalized, provided that Such Medical Expenses were incurred for the same illness/injury for which subsequent Hospitalization was required, and We have accepted an inpatient Hospitalization claim under Inpatient Hospitalization Treatment. (Section A.1)

4.     Post-Hospitalization

        The Medical Expenses incurred during the 90 days immediately after You were discharged post Hospitalization provided that Such costs are incurred in respect of the same illness/injury for which the earlier Hospitalization was required, and We have accepted an inpatient Hospitalization claim under Inpatient Hospitalization Treatment. (Section A.1)”

 

4. Thus, one thing is clear from the terms and conditions of the subject policy, which have not been even disputed by the complainant, that the insured was entitled for in-patient hospitalisation treatment alongwith pre-hospitalisation medical expenses incurred during 60 days immediately before the insured was hospitalised and 90 days immediately after discharge from the hospital, being post hospitalisation charges and for that particular period, whatever bills complainant has raised with the OP, she was certainly entitled for the same.
5. In order to determine if the complainant has raised the medical bills as per terms and conditions of the subject policy, as discussed above, details of bills submitted by her are required to be scanned carefully.  Perusal of the bills (Annexure C-2 Colly.), details of which have been given by her (at page 80-81), indicates that she has even included the bills w.e.f. 5.2.2020 to 20.5.2020 whereas she was required to include the bills as per pre-hospitalisation starting w.e.f. 22.7.2020 i.e. two months prior to her admission in the hospital and three months after her discharge, besides the inpatient hospitalisation, and the said details (available at page 80-81 of Annexure C-2) indicate that the complainant  was entitled to ₹46,701/- as per details below :–

1.	Pre-hospitalisation bills (22.5.2020 to 21.7.2020)	₹23,457/-
2.	In-patient hospitalisation bills (22.7.2020 to 27.7.2020)	₹13,094/-
3.	Post hospitalisation bills (28.7.2020 to 27.10.2020)	₹10,150/-
	Total	₹46,701/-

However, the OP has only allowed claim to the tune of ₹17,683/- i.e. ₹29,018/- less than the amount to which the complainant was actually entitled.  Hence, it is safe to hold that the OP was unjustified in partially repudiating the claim of the complainant and the complainant is certainly entitled to the aforesaid amount alongwith interest and compensation.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OP is directed as under :-

1. to pay ₹29,018/- to the complainant alongwith interest @ 9% per annum from the date of institution of the present consumer complaint i.e. 20.1.2022 onwards.
2. to pay ₹10,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by the OP within forty five days from the date of receipt of its certified copy, failing which, the payable amounts, mentioned at Sr.No.(i) & (ii) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

02/02/2024 hg			[Pawanjit Singh] President
			[Surjeet Kaur] Member
			[Suresh Kumar Sardana] Member