District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.336/2022.
Date of Institution: 22.06.2022.
Date of Order: 03.01.2023.
Manish Kumar son of Shri Charan Singh resident of House No. 237, Village Ajronda, Sector-15A, Faridabad.
…….Complainant……..
Versus
1. Care Health Insurance Company Limited, (Formerly known as Religare Health Insurance Company Limited) tower-C, U it No. 604,605, 606 and 607 6th floor Unitech Cyber Park Sector-39, Gurgaon, Haryana – 122001.
Service will be affected at : Dwarka Complex, SCO 102,103 office No. 219 2nd floor, Sector-16, Faridabad.
2. SSB Central Hospital & Research Centre Ltd. (formerly known as Hospital & Research Center Ltd.) Plot NO. 69, Mathura Road, Near Neelam Flyover Sector-20A, Faridabad.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Thakur Phool Singh, counsel for the complainant.
Opposite party ex-parte vide order dated 30.08.2022.
ORDER:
The facts in brief of the complaint are that the complainant was
the holder of floater mediclaim policy issued by the opposite party No.1 bearing NO. 16731078 valid from 28.01.2021 to 27.01.2022. On 11.03.2021 due to fall at home his client had complaint with pain and tingling on right hand as he was unable to move his right hand so he was admitted in emergency ward of opposite party NO.2 vide UHID No-1IPNO-200134049/31-21/2494 where the medical officer of opposite party No.2 had examined his client and after examination by medical officer of opposite party No.2 they advised the complainant to admit in hospital. After completing all the formalities his client had admitted from 11.3.2021 to 13.03.2021 and on satisfactory condition of complainant was discharged by the medical officer of opposite party NO.2 on 13.03.2021. On 13.03.2021 it comes in the knowledge of the complainant that the opposite party No.1 had cashless denied vide their letter dated 13.03.2021 in the grab “Non Disclosure of material facts pre-existing ailments at the time of proposal – HIGH BMI hence his client had paid all the hospitalization bill which total amounting to Rs.32,548.41 vide bill NO. qcic21/2890 dated 13.03.2022. After refusal of the cashless the complainant had applied for post claim with the opposite party NO.1 on dated 24.11.2021 with the clarification letter of the medical officer of SSB central Hospital & Research Centre Ltd., Faridabad that “there was no relation with HIGH BMI but the opposite party No.1 did not take any heed on the genuine request/post claimed applied by the complainant. The complainant from the date was running from pillar to post but the opposite parties did not release the amount
of claim of the complainant which was already paid by the complainant to opposite party No.2 as the complainant did not know that where was the fault as the opposite party No.1 had ignored the request of the complainant and had not sent the approval of the bills which clearly shows the deficient service in their parts. The complainant sent legal notice dated 15.03.2022 to the opposite parties but all in vain. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) make the entire payment of treatment i.e. a sum of Rs.32548.41/- towards claim amount and post hospitalization bills which was already paid by the complainant to the opposite parties alongwith interest @ 24% from the date of payment till its realization.
b) pay Rs. 50,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 31,000 /-as litigation expenses.
2. Notice issued to opposite party on 27.07.2022 not received back either served or unserved. Tracking details was file don 26.08.2022 in which it had been mentioned that “Item Delivery Confirmed”. Mandatory period of 30 days now expired. Hence, opposite parties Nos.1 & 2 were proceeded against ex-parte vide order dated 30.08.2022.
3. The complainant led evidence in support of his respective version.
4 We have heard learned counsel for the complainant and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against
opposite parties – Care Health Insurance Company Limited with the prayer to: a) make the entire payment of treatment i.e. a sum of Rs.32548.41/- towards claim amount and post hospitalization bills which was already paid by the complainant to the opposite parties alongwith interest @ 24% from the date of payment till its realization. b)pay Rs. 50,000/- as compensation for causing mental agony and harassment . c) pay Rs. 31,000 /-as litigation expenses.
To establish his case, the complainant has led in his evidence Ex.CW1/A – affidavit of Shri Manish Kumar,,Ex.C-1 – letter dated 23.01.2021,, Ex.C-2 – Discharge on Request, Ex.C-3 – Denial letter,, Ex.C-4 – Final Bill of supply summary (Cash), Ex.C-5 – Claim form, Ex.C-6 – certificate,, Ex.C-7 – legal notice,, Ex.C-8 to C-10 – postal receipts,
6. There is nothing on record to disbelieve and discredit the aforesaid ex-parte evidence of the complainant. Since opposite parties Nos1 & 2 have not come present to contest the claim of the complainant, therefore, the allegations made in complaint by the complainant go unrebutted. From the aforesaid ex-parte evidence it is amply proved that opposite parties Nos.1 & 2 have rendered deficient services to the complainant. Hence the complaint is allowed against opposite parties Nos.1 & 2
7. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed. Opposite party No.1 is directed to process the claim of the complainant as per the T&C of the policy within 30 days of receipt of the copy of order and pay the due amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint till its realization. The opposite party No.1 is also directed to pay Rs.2200/- as
compensation on account of mental tension, agony and harassment alongwith Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 03.01.2023 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
