Punjab

Ludhiana

CC/20/313

Sanjeev Kumar - Complainant(s)

Versus

HDFC Ergo General Ins.Co.Ltd - Opp.Party(s)

Sunil Srivastava Adv.

27 Oct 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:313 dated 26.11.2020.                                                         Date of decision: 27.10.2023.

 

Sanjeev Kumar son of Shri Lekh Raj, resident of House No.112, Near Gulabi Kothi, Phillaur, District Jalandhar-144410.                                                                                                                                              ..…Complainant

                                                Versus

1. HDFC ERGO Health Insurance (formerly Apollo Munich Heath Insurance Co. Ltd.), Corporate Office: 1^st Floor, SCF-19, Sector 14, Gurgaon-122001, Haryana through its Director/Managing Director.
2. Apollo Munich Health Insurance Co. ltd., Regd. Office: Apollo Hospitals Complex, 8-2-293/82/JIII/DH/900, Jubilee Hills, Hyderabad, Telangana-500033 through its Director/Managing Director.                                                                                                              …..Opposite parties 

Complaint Under Section 12 of the Consumer Protection Act, 1986.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Sunil Srivastav, Advocate.

For OP1                         :         None for OP1. (Defense of OP1 already struck                                            of vide order dated 01.08.2022)

For OP2                         :         Sh. Alok Mohindra, Advocate.

 

ORDER

PER JASWINDER SINGH, MEMBER

1.                Briefly stated, the facts of the case are that the complainant has been obtaining health insurance policy from OP2 since the year 2014 by paying premium for extending the policy each and every time. Later on, OP2 was merged with OP1. On 14.03.2020, the complainant fell ill and suffered problem in his chest during the subsistence of a cashless policy No.110600/11051/AA00033644-07 having validity from 03.05.2019 to 02.05.2020. The complainant was got admitted in DMC Hospital, Ludhiana on 14.03.2020 and was discharged on 21.03.2020. A sum of Rs.85,613/- were incurred on his treatment which the hospital authorities refused to grant benefit of cashless facility. The complainant applied for disbursement of the amount with the OPs by fulfilling all the formalities but same was not disbursed by the OPs. The complainant also approached the OPs many times with request to disburse the amount and also sent letter through email on 25.05.2020 and through post on 28.05.2020 to the OPs but to no effect. The complainant stated that he has suffered undue harassment and humiliation due to deficiency in service and unfair trade practice on the part of the OPs for which he is entitled to compensation. The complainant sent a legal notice dated 21.07.2020 posted on 27.07.2020 to the OPs but no reply was received. Hence this complaint, whereby the complainant has prayed for issuing directions to the OPs to disburse the amount of Rs.85,613/- along with interest and compensation of Rs.1,00,000/- and litigation expenses of Rs.22,000/-.

2.                Upon notice, Sh. Vyom Bansal, Advocate filed memo of appearance on behalf of OP1 but later on, none turned up for OP1 nor filed any written statement, affidavit and documents and as such, defense of OP1 was struck of vide order dated 01.08.2020.

3.                Upon notice, opposite party No.2 appeared and filed written statement along with affidavit and documents.

                   However, the complainant filed application for striking of the defense of OP2 by stating that OP2 put in appearance on 17.03.2020 but failed to file written reply despite availing opportunities and even after elapsing of statutory period of 45 days to file written statement. The said application was allowed vide order dated 03.03.2023 in terms that the written statement filed by OP2 on 21.12.2021 i.e. beyond the period of limitation cannot be taken on record. It was further directed vide order dated 03.03.2023 that the complaint shall be proceeded further to settle the consumer dispute exparte on the basis of evidence to be brought by the complainant only.

4.                In support of his claim, the complainant tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 is the copy of renewal of policy/documents w.e.f. 03.05.2019 to 02.05.2020, Ex. C2 is the copy of discharge summary, Ex. C3 is the copy of in-patient final bill dated 21.03.2020, Ex. C4, Ex. C5 is the copy of email dated 26.05.2020, Ex. C6 is the copy of postal receipt, Ex. C7 is the copy of track consignment record, Ex. C8 is the copy of legal notice dated 21.07.2020,  Ex. C9 and Ex. C10 are the copies of postal receipts, Ex. C11 is the copy of registration card of the complainant, Ex. C12 is the copy of ID card of the complainant, Ex. C13 to Ex. C39 are the copies of bills and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents by the complainant.

6.                Admittedly, Ex. C1 policy documents shows that the complainant has been availing Easy Health Floater Standard policy from the OPs since 12.02.2014 for himself, his wife Mrs. Shivani and sons Master Vasu and Master Vaibhav. The complainant got renewed the policies from time to time and currently is covered vide policy w.e.f. 03.05.2019 to 02.05.2020. The complainant was got admitted in Dayanand Medical College and Hospital, Ludhiana on 18.03.2020 where he was diagnosed of B/L/ Basal Pneumonia, Type-2 DM, HTN and Old H/O CVA and was discharged on 21.03.2020. The complainant incurred Rs.71,779/- on his treatment as per in-patient final bill Ex. C3 which the OPs failed to disburse to the complainant. Though the evidence has gone unrebutted on the file, the in-patient final bill Ex. C3 reveals that the complainant spent Rs.71,779/- on his treatment taken from Dayanand Medical College & Hospital, Ludhiana. In these circumstances, it would be just and proper if the opposite parties are directed to settle and reimburse the claim of the complainant as per in-patient final bill Ex. C3 to the complainant subject to furnishing of requisite documents. The OPs are also burdened with composite cost of Rs.10,000/-.

7.                As a result of above discussion, the complaint is partly allowed with an order that the complainant will facilitate the OPs for submission of requisite documents, if requisitioned by the OPs during course of settlement of the claim, within 15 days from the date of receipt of copy of order and thereafter, the Ops shall settle and reimburse the claim of the complainant as per in-patient final bill Ex. C3 within 30 days after receipt of the requisitioned documents from the complainant. The OPs shall further pay a composite compensation of Rs.10,000/- (Rupees Ten Thousand only) to the complainant. Compliance of order be made within 30 days from the date of receipt of copy of the order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

8.                Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                       President         

 

Announced in Open Commission.

Dated:27.10.2023.

Gobind Ram.