Before the District Consumer Disputes Redressal Forum, Rohtak.
Complaint No. : 14.
Instituted on : 13.01.2014.
Decided on : 10.05.2016.
Bijender Singh s/o Sh Raghbir Singh, resident of H.No.556-B, Ward No.29, Kamal Colony, Rohtak.
………..Complainant.
Vs.
Birla Sun Life Insurance Company Ltd., Rohtak through its Manager.
……….Opposite party.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.JOGINDER KUMAR JAKHAR, PRESIDENT.
MS. KOMAL KHANNA, MEMBER.
SH. VED PAL, MEMBER.
Present: Sh.Tarun Hooda, Advocate for the complainant.
Sh.Gulshan Chawla, Advocate for the opposite party.
ORDER
SH. JOGINDER KUMAR JAKHAR, PRESIDENT :
1. The present complaint has been filed by the complainant with the averments that he took “Birla Sunlife Insruance Hospital Care Rider” (BSLI Vision Plan) vide policy bearing no.004890230 from the opposite party/respondent for the sum assured Rs.150000/-. It is averred that on 08.04.2012 complainant fell down in bathroom of his house and thereafter he was admitted in the Sun Flag Hosptial Rohtak for treatment and it was found that complainant was suffering from left leg fracture and requires operations. It is averred that complainant was got operated and spent an amount of Rs.38629/- and applied for insurance claim under the policy. Complainant made so many requests to the opposite party to pay the claim amount but any heed was not paid to his requests. It is averred that after repeated requests of the complainant, the opposite party sent a cheque bearing no.000619 dated 11.11.2013 amounting to Rs.1200/- against the claimed amount of Rs.38629/- which is against the terms and conditions of the policy. It is averred that opposite party may kindly be directed to pay the remaining amount of Rs.37429/- alongwith interest, compensation and litigation expenses to the complainant.
2. On notice opposite party appeared and filed its written reply submitting therein that it is wrong and denied that the complainant has spent an amount of Rs.38629/- on alleged treatment. That the claim of the complainant was decided on merits and an amount of Rs.1200/- as per terms and conditions of the policy has been paid to the complainant. It is averred that the cheque amount has been got encashed by the complainant without any protest and hence the present complaint is liable to be dismissed. All the other contents of the complaint were stated to be wrong and denied. Opposite party prayed for dismissal of complaint with costs.
3. Both the parties led evidence in support of their case.
4. Ld. counsel for the complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C39 and has closed his evidence. On the other hand ld. Counsel for the opposite party has tendered affidavit Ex.RW1/A, documents Ex.R1 to Ex.R3 and has closed his evidence.
5. We have heard ld. counsel for the parties and have gone through the material aspects of the case carefully.
6. In the present case insurance and treatment of life assured is not disputed. After the treatment complainant filed the claim with the opposite party but the opposite party had only paid an amount of Rs.1200/- through cheque no.000619 Ex.C39 on account of claim on the ground that as per terms and conditions of the policy the calculation of amount payable is No. of days * 0.4% of Sum Assured which is 2 * 0.4 of Rs.150000/- i.e. Rs.1200/-. It is further contended that the alleged cheque has already been got encashed by the complainant without any protest and hence the present complaint is liable to be dismissed.
7. After going through the file and hearing the parties it is observed that as per terms and conditions of the policy placed on record as Ex.R3, under the head Hospital Care benefit, the total benefit amount shall be 0.4% (or 1/250th ) of the rider sum assured for each day of hospitalization starting from the date of admission to the hospital. As per claim form Ex.C2, the date of admission in the hospital was 08.04.2012 and date of discharge is 10.04.2012. Accordingly as per terms and conditions of the policy, the amount payable was No. of days * 0.4% of Sum Assured i.e. 2 * 0.4 of Rs.150000/- = Rs.1200/- which has already been paid to the complainant.
8. In view of the facts and circumstances of the case, it is observed that the claim has already been paid to the complainant. Hence he is not entitled for any further claim. As such the present complaint stands dismissed with no order as to costs.
9. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
10.05.2016.
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Joginder Kumar Jakhar, President
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Komal Khanna, Member.
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Ved Pal, Member.
