BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, JALANDHAR.

 Complaint No.207 of 2019

      Date of Instt. 12.06.2019

      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 complainant and allured her to purchase the cashless medical insurance policy of OP. The agent of OP assured the complainant that in case of sickness, if the complainant is hospitalized in any authorized hospital of Bajaj Allianz for any problem, the OPs will bear all the expenses and pay the amount directly to the hospital starting from day of admission on till discharge. If the hospital is not empanelled by company then reimbursement will be made. The agent of the OP also insured to reimburse the medical expenses incurred during the 60 days immediately before the hospitalization and for 90 days after the discharge from hospital. That at the assurance of OP, the complainant 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 29.04.2019, the complainant felt vomiting and dysentery with stomach pain. Then she went to doctor’s clinic near her house. The doctor gave medicine for 3 days. But, the complainant did not feel better. On 03.05.2019, the condition of the complainant worsened and she was brought to Modern Hospital, Jalandhar. There was no senior doctor present, Junior doctors gave a Perinorm and Voverin injection and also gave two capsules for the treatment of the loose motions and sent back the complainant to her home. But the complainant did not feel better till evening. The the complainant was brought to Baweja Hospital, Jalandhar. Dr. Baweja admitted the complainant in the hospital. The agent of the OP company was telephonically informed about the admission of the complainant in the hospital, but the agent of the OP did not give any response. That on 05.05.2019 the complainant was discharged from the hospital. On the next day the complainant tried to submit the hospital bills for reimbursement but she was not entertained by the OP. That there is deficiency in service of the OP in providing insurance claim to the complainant and due to non-payment of claim amount, the complainant has suffered financial loss and mental tension. The complainant has served a legal notice on 25.05.2019 upon the OPs, but all in vain 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.16,266/- alongwith interest and cost of litigation Rs.10,000/- and Rs.10,000/- as compensation for the harassment to the claimant.

2.                Notice of the complaint was given to the OPs, who 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. No claim whatsoever with regard to any treatment of the complainant in Baweja Hospital and Maternity Hospital, Jalandhar for the period 03.05.2019 to 05.05.2019 has been lodged by the complainant, as such, the complaint is liable to be dismissed. It is further averred that the complainant cannot take advantage of her own wrongs. It is the complainant, who is at fault by not making any request for pre-authorization for cashless treatment nor lodging claim for reimbursement of the medical treatment expense with the OP alongwith the requisite claim documents. The complainant has no locus-standi to file the present complaint. 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 felt vomiting and dysentery with stomach pain on 29.04.2019. She went to her doctor and took medicine as per his prescription, but that treatment did not go well. She took treatment from Modern Hospital, Jalandhar, but again she did not feel well and she was admitted to Baweja Hospital, Jalandhar. She was discharged from hospital on 05.05.2019. It has been alleged by the complainant that on the next day the complainant tried to submit the hospital bills for reimbursement but she was not entertained by the OP. 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-3.

7.                The contention of the OP is that no claim whatsoever with regard to any treatment of the complainant in Baweja Hospital and Maternity Hospital, Jalandhar for the period 03.05.2019 to 05.05.2019 has been lodged by the complainant and as such, the complainant is not entitled to any relief as the complainant has never filed the claim for reimbursement. 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 on telephone and on the next day the complainant tried to submit the hospital bills for reimbursement but she was not entertained by the OP. Thereafter the complainant never filed and lodged any claim for reimbursement nor submitted any document before the OPs as per terms and conditions of the 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