Smt. Sangita Paul, Member

         That the case was filed by Shri Sohel Sardar S/o. Soharab Sardar of 30 Hasampur Road, Joynagar Majilpur Municipality, P.O. – Joynagar Majilpur, P.S. – Joynagar, district – South 24 Parganas, Pin – 743 337 against Director of Aditya Birla Health Insurance co. Ltd. With a prayer for directing the OP to pay Rs.3,47,500/- with 11% interest till realizsation.

The OP is the Director, Aditya Birla Health Insurance Co. Ltd.  The address is PLC 26377, 10^th Floor, R-Tech, Park Nirlon Compound.  Next to HUB Mall off Western Express, Highway, George.

The complainant by filing this case states that he is an employee of H.D. Finance Ltd. Under the jurisdiction of South 24 Parganas.  The complainant’s employer made an insurance policy, including the accident benefit of Rs.5,00,000/-.

As the complainant is an employee, his name was also included in the list as a policy bolder.  The policy number is 51-10-00929-0000, insured code No. is HFO 33262, the insured location is Mumbai, the insured mobile No. is 9647013162, the insured name is Sohel Sardar PHS id is 16867820.

On 26.06.2020, the complainant met with an accident while he was on duty at Lazmikantapur under P.S. Mandir Bazar, South 24 Parganas.  He had a bone ancle fracture and other injuries on the body.  The complainant was treated primarily at a local nursing home.  But the condition was becoming so serious that the operation of fractures was very much urgent and the doctor was suggesting for setting steel place.  Aditya Birla Hospital denied to serve during COVID-19 situation.  In the meantime, the Lock down was also declared.  The hospitals and nursing homes declared that COVID 19 test was mandatory.  The report will come after 5 days.  The complainant was not in a position to wait for sucha a long period of time.  At laswwt the complainant was admitted to a private hospital on 30.06.2020 and that the complainant was operated on that very day at AL-Amin Nursing Home.  Ghatakpukur, South 24 Parganas.  Two plates were set up in the left ankle.  The nursing home discharged the complainant on 12.07.2020.

The complainant communicated with the company h. D. Finance.  Each and every document was placed before Aditya Birla Health Insurance Co. Ltd.  The company also demanded license of the Hospital where the complainant was operated.  The complainant submitted but the Health Insurance Company did not disburse the bill.  The complainant served a Demand Notice through his advocate on 06.06.2022.

The cause of action for filing the complainant arose on 30.06.2020 and lastly on 06.06.2022.

Hence the complainant prays for directing the OPs to pay Rs.3,47,500/- along with 11% interest as medical expense, in favour of the complainant.

That the case was filed on 19.07.2022.  The case was admitted on 29.07.2022.  On 17.11.2022, Ld. Lawyer of the complainant files track report along with postal receipt.  The track report revealed that the OP received notices on 20.10.2022.  On the next date i.e. on 06.12.022, the statutory period for filing W/V was expired.  Hence the case proceeded ex-parte against the OP.  On 18.01.2023, the complainant files evidence on affidavit.  On 13.03.2023 the complainant files BNA.  On 29.03.2023 argument was heard.  Accordingly, we proceeded for giving judgement. 

                                    Points for consideration :-

1. Is the complainant, a consumer?
2. Is the OP guilty of deficiency in service and unfair trade practice?
3. Is the complainant entitled to get relief as prayed for?

Decision with reasons :-

Point No.1:- 

On perusal of the documents and records, it appears that the complainant sustained severe injury on his ankle and other parts of the body.  A considerable amount of Rs.3,47,000/- was spent.  Besides, there were other expenditures related to operation.  S the complainant spent for his operation, he is a consumer U/S 2(7) of the C.P. Act, 2019.

Point No:2 : 

The complainant an employee of H.D. Finance.  On 22.06.2020, the complainant met with an accident.  His left ankle was severely injured.  Besides, he had other injuries.  The complainant went to the listed hospitals of Aditya Birla Health Insurance.  They were not ready to operate without COVID-19 certificate.  It will take 5 days to obtain COVID-19 certificate.  By that time, the injury would be aggravated and it would be detrimental for the complainant because the injury was severe.  As a result, the complainant was operated at Al-Amin Nursing Home.  The plates were set up on his left ankle.  Besides there were other injuries.  The complainant communicated with H.D. Finance.  He placed all the documents, related to operation and treatment.  They told the complainant to submit the licence of Al Amin Nursing Home.  It appears that the OP is reluctant to settle the claim of the complainant.  It is clear that the complainant is entitled to receive the medical expenses incurred by the complainant.  Being a staff of H.D. Finance, his medical expenses must be disbursed by the Aditya Birla Health Insurance Company.  A legal notice was also served on 06.06.2022, in this regard.  The Health Insurance Company wanted from the complainant the details of the policy.  Everything was mentioned to the OP   Still the OP is delaying in disbursing the claim.  All the relevant papers were submitted.  It is due to the deficiency in service and unfair trade practice of the OP that the OP is delaying unnecessarily.  Hence, the 2^nd point is settled in favour of the complainant. 

Point No.03 :-

The complainant being a staff of the H. D. Finance is entitled to get the Health Insurance benefits.  The complainant met with an accident.  His left ankle was injured.  Besides he sustained other injuries.  Two plates were set up on his left ankle.  The complainant spent Rs.3,47,000/- for operation.  The claim type was reimbursement.  But the complainant is yet to get the reimbursement.  Hence the complainant spends time in mental agony and pain.  He is entitled to get relief as prayed for.  So the 3^rd point is decided in favour of the complainant and against the OP.

In the result, the complaint case fails.

Fees paid is correct.

Hence, it is,

                                                                                     ORDERED

That the complaint be and the same is allowed on contest with cost of Rs.10,000/- (Rupees ten thousand).

That the OP is directed to pay Rs.1,97,000/- (Rupees one lakh and ninety seven thousand) as cost of operation, medicine bill and dressing charge, with 9% interest w.e.f. 30.06.2020 t the complainant within 45 days from the date of this order. 

That the OP is directed to pay compensation to the tune of Rs.50,000/- (Rupees fifty thousand) to the complainant within 45 days from the date of this order.

That the litigation cost of Rs.10,000/- (Rupees ten thousand) is to be paid by the OP within 45 days from the date of this order.

Ld. Member Sri Partha Kumar Basu joined on 11.04.2023 and he did not take part in hearing the argument of the case.  As such he did not sign the judgement and order passed on this day. 

Let a copy of this order be supplied to the parties concerned free of cost. 

That the final order will be available in the following website: www.confonet.nic.in.

Dictated and corrected by me.  

Sangita Paul                   

               Member