BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

 Complaint No.122 of 2019

      Date of Instt. 18.04.2019

      Date of Decision: 01.12.2021

Jaswinder Kaur age 53 years W/o Gurvinder Paul Singh Rana, R/o 77, Vasant Avenue, Jalandhar.

..........Complainant

Versus

1.       Bajaj Allianz General Insurance Company Ltd. Through its      CEO/Manager, IInd Floor, Satnam Complex, B. M. C. Chowk, G. T. Road, Jalandhar.

2.       Bajaj Allianz General Insurance Company Ltd. GE Plaza, Airport      Road, Yerwada, Pune.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before:        Dr. Harveen Bhardwaj             (President)

                   Smt. Jyotsna                            (Member)                                          Sh. Jaswant Singh Dhillon       (Member)

Present:        Sh. G. P. S. Rana, Adv. Counsel for the Complainant.                     Sh. R. K. Sharma, Adv. Counsel for OPs No.1 and 2.

Order

Dr. Harveen Bhardwaj (President)

1.                This complaint has been filed by the complainant, wherein she has alleged that during the month of July 2017, the agent of OP named Rama Rakshak contacted the claimant and allured her to purchase the cashless medical insurance policy of OP. The agent of OP assured the claimant that in case of sickness, if the claimant is hospitalized in any authorized hospital of Bajaj Allianz for any problem, the company will bear all the expenses and pay the amount directly to the hospital starting from day of admission on till discharge. The agent of the OP also insured to reimburse the medical expenses incurred during the 60 days after the discharge from hospital. That at the assurance of OP, the claimant paid sum of Rs.25,571/- and was issued policy No.OG-18-1202-8430-00000517 valid from 25.08.2017 to 24.08.2018. That at the time of issuing policy the OP got the complaint medically examined through his empanelled doctors and was found fit for issuing insurance policy. That the policy was renewed on 22.08.2018 and complainant paid Rs.25,571/- and policy is valid from 25.08.2018 to 25.08.2019. That on 10.02.2019, the claimant was not feeling well and had some fever and abdominal pain, she contacted her doctor, telephonically and asked for advice. The advices CBC and widal test. That the doctor advised medicine and claimant took medicine for typhoid. But after treatment the claimant had still abdominal pain. The claimant went to SGL Hospital, Jalandhar on 12.02.2019 and Dr. Disha Sayal advised for Ultrasound. She gave medicine for stomach infection and advised plenty of water. But the claimant felt no relief after taking medicine. So, on 18.02.2019 she went to new Ruby Hospital Pvt. Ltd., Jalandhar which is an empanelled hospital of Bajaj Allianz Insurance Co. Ltd. She was admitted to Hospital. The hospital staff did USG, Endoscopy, urine test and blood test. The doctors treated with antibiotics for infection and mil esophagitis. The complainant was discharged from hospital 23.02.2019. That immediately after the admission in hospital the hospital staff sent an email to the OP for approval of cashless treatment, which was not replied by the company during the whole period of stay in hospital which caused stress to the claimant and her family. The family of the claimant called the company agent again and again to pursue the matter but no reply was received by the hospital. On the day of discharge i.e. 23.02.2019, the OP refused to pay the bill of hospital and repudiated the claim of the claimant. The claimant had to arrange the money to pay hospital bill and get discharged from hospital. Till date, the claim has not been paid to the complainant and finally the OP refused to release the payment of insurance claim to the claimant. That there is deficiency in service of OP in providing insurance claim to the claimant and due to non-payment of claim amount, the claimant has suffered financial loss and mental tension and as such, the present complaint filed with the prayer that the complaint of the complainant may kindly be accepted and OPs be directed to pay an amount of Rs.54,191/- alongwith interest and cost of litigation Rs.10,000/- and Rs.40,000/- as compensation for the harassment to the claimant.

2.                Notice of the complaint was given to the OPs and accordingly, OPs filed reply and contested the complaint by taking preliminary objections that the complaint is not maintainable against the OPs as the same is pre-matured. It is further averred that the complainant has not approached the OPs for lodging the claim for reimbursement of the medical treatment expense after denial of cashless facility, as such, the complaint is pre-matured and the same is liable to be dismissed. It is further averred that the complainant cannot take advantage of her own wrongs. The complainant has no locus-standi to file the present complaint. It is further averred that the complainant has violated the terms and conditions of the policy, therefore not entitled for any claim. That the complainant is estopped by her own act and conduct from filing the present complaint, as the complaint has been filed without any cause of action. On merits, it is admitted that the complainant purchased insurance policy, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.

3.                Rejoinder to the written statement filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied those of the written statement.

4.                In order to prove their respective versions, both the parties produced on the file their respective evidence.

5.                We have heard the learned counsel for the respective parties and have also gone through the written arguments submitted by both the parties as well as case file very minutely.

6.                The complainant has alleged in the complaint that the claimant purchased an insurance policy after paying the premium of Rs.25,571/- and the policy was valid from 25.08.2017 to 24.08.2018, which was later on renewed on the payment of the premium of Rs.25,571/- and the same was valid from 25.08.2018 to 24.08.2019. The claimant fell ill and had some fever and abdominal pain on 10.02.2019. She contacted her doctor and took medicine as per her prescription, but that treatment did not go well. She took treatment from SGL Hospital, Jalandhar, but again she did not feel well and she was admitted to Ruby Hospital Pvt. Ltd. Lajpat Nagar, Jalandhar on 18.02.2019. She spent huge amount as she was treated with antibiotics for infection and mild esophagitis. She was discharged from hospital on 23.02.2019. It has been alleged by the complainant that after the admission in hospital, the hospital staff sent an email to the OPs for approval of cashless scheme, which was never replied by the company and the family of the complainant called number of times to the OPs, but there was no response. When she was discharged on 23.02.2019, the OPs refused the bill and the claim has not been paid to the claimant. All these facts are proved by the complainant by filing the documents i.e. policy of insurance as Ex.C-1, confirmation of medical examination as Ex.C-2, bills of the hospital and diagnosis of the hospital as Ex.C-4 & Ex.C-5 and vide Ex.C-6, OP has refused the claim.

7.                The contention of the OP is that once the claim for cashless insurance was refused, the complainant is not entitled to any relief as the complainant has never filed the claim for reimbursement. As such no cause of action has accrued to the complainant to file a consumer complaint rather the instant complaint is pre-mature and request has been made to dismiss the claim.

8.                As per the record furnished by the complainant and as per the affidavit, the intimation of her illness and admission was given to the OPs and the cashless relief was claimed, but the same was refused. Thereafter the complainant never filed and lodged any claim for reimbursement nor submitted any document before the OPs as per the terms and conditions of insurance policy. In these circumstances, the complaint is pre-mature. The complainant is required to submit in writing the insurance claim for reimbursement alongwith other relevant documents to OPs for deciding the same and thereafter a cause of action shall accrue to the complainant to file a consumer complaint in case of any adverse order.

9.                Thus, the present complaint of the complainant is disposed of with the direction to the complainant to submit an insurance claim for reimbursement in a proper form alongwith the documents, whatsoever required to the OPs, within 20 working days from the date of receipt of the copy of this order and after receiving the required documents from the complainant, the OPs are directed to decide the insurance claim of the complainant for reimbursement within 30 days from the date of receipt of the documents, failing which the OPs will be liable to pay compensation of Rs.20,000/- to the complainant. It is further ordered that if the complainant will not satisfy with the settlement of the claim made by the OP, then complainant is at liberty to file a fresh complaint. This complaint could not be decided within stipulated time frame due to rush of work.

10.              Copies of the order be sent to the parties, as permissible, under the rules. File be indexed and consigned to the record room after due compliance.

Dated          Jaswant Singh Dhillon    Jyotsna                Dr.Harveen Bhardwaj     

01.12.2021         Member                          Member           President