BEFORE THE DISTT.CONSUMER DISPUTES REDRESSAL FORUM; FATEHABAD.
Complaint Case No.339 of 2015.
Date of Instt.: .08/09.12.2015.
Date of Order: 23.02.2017.
Ikbran Mohmmed son of Karmudin resident of Bhodia Khera, Tehsil & District Fatehabad -125050 Mobile No.99919-32786.
...Complainant
Versus
Bajaj Allianz General Insurance Company Limited 2nd Floor Bajaj Finsev Building Survey No.208/1 B, Behind Weik Field IT Park, Viman Nagar, Pune Maharashtra-411014, through its Manager.
..Opposite party.
Before: Sh.Raghbir Singh, President.
Smt.Ansuya Bishnoi,Member.
Present: Sh. Inder Sihag, counsel for the complainant.
Sh. U.K.Gera, counsel for OP.
ORDER
Sh.Ikbran Mohmmed-complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against the opposite party (hereinafter to be referred as OP).
2. Briefly stated the facts of the present case are that the complainant had obtained a Health Cover Insurance Policy bearing No.OG-15-1207-6001-00000066 dated 26.08.2014 from OP valid from 30.08.2014 to 25.08.2015 after paying requisite premium of Rs.2627/- and as per terms and conditions of policy the OP would borne the expenses in case if the complainant fell ill during the subsistence of the policy. It has been further averred that the complainant fell ill and remained admitted in Balaji Hospital & Trauma Centre, Gurgaon from 17.06.2015 to 22.06.2015 and had spent Rs.37414/- in total for the treatment etc. It has been further averred that thereafter the complainant had applied for reimbursement of the amount spent by him during treatment and submitted claim form with all requisite documents but the OP repudiated his claim vide letter dated 17.08.2015 with the remarks that Verification of the claim documents reveal aforesaid claimant was hospitalized for investigation and treatment of Malarial Fever with Urinary Tract Infection. We have noticed certain discrepancies and lapses in the claim documents on basis of which the claim stands repudiated. The OP has wrongly and illegally repudiated the claim of the complainant and it clearly amounts to deficiency in service on its part. Hence, this complaint. In evidence, the complainant has tendered his affidavit Ex.CW1/A and documents Annexure C1 to Annexure C18.
3. Upon notice, OP appeared and contested the complaint by filing reply wherein it has taken many preliminary objections such as cause of action, locus standi, maintainability and estoppel etc. It has been further submitted that insurance policy is a contract and both the parties are under obligation to abide by its terms and conditions but major discrepancies were found in the statement given by the complainant during investigation conducted by MacCoy Consultancy Services Private Limited Lucknow. It has been further submitted that the complainant had neither fallen ill nor remained admitted in hospital and the documents/papers shown by him regarding admission in hospital are forged and fabricated as these indicate that the same these have been prepared in order to extend the period of hospitalization because as per vital charts, temperature was continuously raised even though injection PCM 100 Ml infusion was administered three times daily. It has been further submitted that the lab tests of the complainant were shown to be got done from Bhumi Path Lab run by Vaibhav, DMLT without association of any pathologist. Other allegations made in the complaint have been denied and it has been denied that there is any deficiency and unfair trade practice
on behalf of OP. Prayer for dismissal of the complaint has been made. In evidence, the Op has tendered affidavit of Sh.Navjeet Singh, Assistant Manager as Annexure R1 and document Annexure R2.
4. Heard. Learned counsel for complainant has reiterated the averments made in the complaint and prayed for its acceptance. On the other hand, learned counsel for OP has reiterated the averments taken in the reply and prayed for dismissal of the complaint.
5. It has been established on record that complainant had obtained Generic Contingency Policy Schedule (Annexure C2) Section Health Guard-Family Floater covering the risk of hospitalization from OP which was valid from 30.08.2014 to 25.08.2014 and he had also paid the premium thereof vide cheque No.009979 dated 26.08.2014 (Annexure C4). The OP had also issued Health and Wellness Cards to the complainant which have been placed on the case file as Annexure C7 and Annexure C8 respectively. It is also established on case file that the complainant had fallen ill and was admitted in Bala Ji Hospital, Gurgaon on 17.06.2015 (Annexure C14) and discharged on 22.06.2015 (Annexure C15). Perusal of documents Annexure C11 to Annexure C13 reveals that the complainant had spent Rs.37614/- (Rs.13000+Rs.18000+Rs.6414= 37614). The complainant has come with the plea that he had fallen ill and remained hospitalized during subsistence of the policy but the OP has wrongly and illegally denied to reimburse the amount spent on his treatment despite receiving of premium before issuance of the policy in question. On the other hand the OP has come with the plea that there are many discrepancies and lapses in the claim documents, therefore, his claim was rightly repudiated.
6. After hearing rival contentions of the parties and going through the material available on the case file this Forum is of the opinion that the OP has wrongly repudiated the claim of the complainant. One thing we should note that why a person purchases a health insurance cover. Certainly, by keeping in mind that Health Insurance is an insurance against the risk of incurring medical expenses and having insurance can help/protect insured from high medical costs and it may also help to cover expenses if insured needs unexpected care. In the present case the complainant had obtained the policy in question in order to safeguard/covering the unexpected care by paying premium to the tune of Rs.2627/-. Unfortunately, he fell ill and had spent Rs.37414/- on his treatment but when he had submitted his claim for reimbursing the alleged amount then the insurance company in order to avoid its liability has repudiated the same on one pretext or the other without leading any cogent and documentary evidence. It has been noticed by this Forum that except final report given by MacCoy Consultancy Services Pvt. Ltd. there is no other evidence on record to prove the discrepancies and lapses the insured had committed which makes him disentitle to reimburse the amount spent by him on his treatment. Moreover, this report also cannot be termed as a document on the basis of which the genuine claim of the complainant can be terminated. No doubt the OP has also tendered affidavit of Sh.Navjeet Singh, Assistant Manager (Annexure R1) but there is not even a single piece of evidence on record to prove the defence taken by the OP. The plea of the OP that the complainant had fabricated and forged the documents in order to show the extended hospitalization by the complainant is also remained unproved as the OP has not brought any affidavit of the treating doctor or any specialist in order to strengthen its plea. The rejection of claim by the OP was totally uncalled for. The insurance companies are not supposed to obtain only premium but it shows that as and when any genuine claim is raised then it bent upon to reject the same on false and flimsy grounds. Mere pleadings without concrete evidence have no value in the eyes of law. On this point reliance can be taken from case law titled as Vinod Kumar Versus Punjab State Electricity Board & Ors., III (2011) CPJ 194 (NC). In the present case the OP has not acted fairly which amounts to deficiency in rendering service and adoption of unfair trade practice on its part.
7. Thus, as a sequel to our above discussion, we are of the considered opinion that there is deficiency in service on the part of OP. Hence, we accept the present complaint and direct the OP to reimburse the amount of Rs.37414/- spent by the complainant on his treatment alongwith interest @ 6% per annum from the date of filing of present complaint till actual realization. This order should be complied within a period of one month, failing which the complainant will be entitled to initiate proceedings under Section 25/27 of the Act against the opposite party. A copy of this order be supplied to the parties free of costs. File be consigned to the record room after due compliance.
Announced in open Forum.
Dated: 23.02.2017
(Raghbir Singh)
President
(Ansuya Bishnoi) Distt.Consumer Disputes
Member. Redressal Forum, Fatehabad.
