Haryana

Fatehabad

CC/99/2019

Des Raj - Complainant(s)

Versus

Bajaj Allianz General Insurance - Opp.Party(s)

Virender Jakhar

20 Nov 2023

ORDER

BEFORE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, FATEHABAD.

 

                                      Sh.Rajbir Singh, President.                                               Dr.K.S.Nirania and Smt.Harisha Mehta, Members

 

                                             Complaint Case No.: 99 of 2019.

                                             Date of Institution:      25.02.2019

                                                        Date of order:            20.11.2023.

         

Des Raj son of Nand Lal r/o village Nanheri Tehsil Tohana District Fatehabad.

 

                                                                          ….. Complainant.                            

                                      Versus

 

1.Bajaj Allianz General Insurance Company Limited, GE Plaza,Airport Road, Yerawada Pune 411006, through its authorized person.

2.Bajaj Allianz General Insurance Company Limited through its authorized agent, Yes Bank, Limited, Ground Floor No.118, SBI Road, Jain Tower, Anaj Mandi Fatehabad through its Branch Manager.

….Opposite parties.

 

Complaint U/s 35 of the Consumer Protection Act,2019

    

Present:           Shri Virender Jakher, Advocate for complainant.

                   Shri U.K.Gera, Advocate for opposite party No.1.                                     Shri Neeraj Asija, Advocate for opposite party No.2.

 

ORDER

SH.RAJBIR SINGH, PRESIDENT

                   Brief facts of the present complaint are that the complainant had purchased a health insurance policy bearing No.OG-17-1207-8401-00000033 having validity from 10.06.2016 to 09.06.2017; that the complainant felt ill and  remained admitted in Pal Hospital and Maternity Centre Ratia and spent Rs.29025/- on his treatment and hospitalization; that the complainant submitted all the requisite documents with Ops for reimbursement of the amount but despite that the amount has not been released till date.  The act and conduct of the Ops clearly amounts to deficiency in service on their part. Hence, this compliant.

2.                          On notice, Ops appeared and filed their separate written statements. OP No.1 in its reply has taken preliminary objections such as cause of action and locus standi etc. It has been further submitted that the patient was discharged from the hospital on 15.09.2016 as per admission register but as per doctor and discharge card, patient was discharged from the  hospital on 16.09.2016; that the complainant overstayed in the hospital in order to add extra charges in his final  bill, therefore, the claim of the complainant was rightly repudiated as per the terms and conditions of the policy. Other contentions have been controverted and prayer for dismissal of the complaint has been made.

3.                          OP No.2 in its reply has taken preliminary objections such as cause of action, maintainable, concealment of material facts and locus standi etc. It has been further submitted that replying Op was the agent of Op No.1 till 30.09.2018 and after issuance of the insurance policy, the complainant had never approached the replying Op, therefore, all the responsibilities of the claim are of Op No.1. There is no deficiency in service on the part of replying Op. Other contentions have been controverted and prayer for dismissal of the complaint has been made.

3.                          In evidence, the complainant has tendered affidavit Annexure CW1/A with documents Annexure C1 to Annexure C14 and. On the other hand, the Ops have tendered affidavits Ex.RW1/A, Annexure R1 and documents Annexure R1 to Annexure R4

4.                          We have heard oral final arguments from both sides. We have also perused the case file minutely.

5.                          The ground for repudiation of the claim of the complainant as mentioned in repudiation letter (Annexure R2) is that on detailed scrutiny of the same, we find that the claim does not fall under the purview of the policy because as per the verification of the claim documents reveal that the claimant was hospitalized for investigation and treatment of Acute Gastroenteritis. We have noticed certain discrepancies and lapses in the claim documents on basis of which the claim stands repudiated.  The OP No.1 in the reply has mentioned that the patient was discharged from the hospital on 15.09.2016 as per admission register but as per doctor and discharge card, patient was discharged from the  hospital on 16.09.2016 which shows that the complainant overstayed in the hospital in order to add extra charges in his final bill and due to this reason the claim was rightly repudiated.

6.                          In order to reach at any conclusion let us see the discharge summary of the complainant wherein the doctor has specifically mentioned that the patient was discharged in the morning of 16.09.2016 and the stay was for 3 days.  The complainant had submitted the claim form for amount of Rs.29025/- wherein the hospital charges has been mentioned as Rs.15,000/- and rest of the amount has been shown on other counts such as medicines, pharmacy bills and lab charges.  The hospital where the complainant remained admitted had issued bill, which is placed on case file as Annexure R4, to the tune of Rs.15,000/-.

7.                          After going through the material available on the case file, we have no hitch to say that the Ops have not led any evidence to show that the complainant has ever overstayed in the hospital for adding extra charge in the final bill rather the discharge summary issued by the concerned shows that the complainant had stayed in the hospital for three days and in the bill the rent charges Rs.1500x3= 4500/- has been mentioned out of the total bill of Rs.15,000/- and the complainant has also mentioned this very amount in the claim form Annexure R3, therefore, the plea of the adding extra charge by overstaying in the hospital by the complainant does not survive anymore and the same is hereby rejected.  Since the complainant has failed to produce on the case file the bills showing he had spent Rs.6,006/- Rs.1723/-, Rs.1732/- on medicines and an amount of Rs.2850/- on lab tests, therefore, the complaint deserves acceptance partly to the tune of Rs.15,000/- only as the concerned hospital had issued the bill to the tune of Rs.15,000/- (Annexure R4).

8.                          Keeping in view the above facts and circumstances of the case we allow the present complaint partly with a direction to the Ops to pay Rs.15,000/- (Rs.Fifteen Thousand only) alongwith interest @ 6 % per annum from the date of filing of the complaint till its realisation. We further allow Rs.11,000/-, (Rs. Eleven Thousand) in lump sum, towards mental harassment and agony suffered by the complainant and also towards litigation expenses. The liability of the Ops is joint as well as several. The order be complied within a period of 45 days from today failing which the awarded amount would carry interest @ 9 % per annum from the date of filing of the compliant till its realization.

9.                          In default of compliance of this order, proceedings against respondents shall be initiated under Section 72 of Consumer Protection Act, 2019 as non-compliance of court order shall be punishable with imprisonment for a term which shall not be less than one month, but which may extend to three years, or with fine, which shall not be less than twenty five thousand rupees, but which may extend to one lakh rupees, or with both. A copy of this order be sent to the parties free of cost. This order be also uploaded forthwith on website of this Commission, as per rules, for perusal of parties herein. File be consigned to the record room after due compliance.     

Announced in open Commission.                                                            Dated: 20.11.2023

 

                                                                                                        

          (K.S.Nirania)                       (Harisha Mehta)                (Rajbir Singh)                              Member                               Member                                           President