DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/83/2022
Date of Institution: 07.03.2022
Date of Decision: 28.06.2024
1. Jang Bahadur Goyal aged about 46 years son of Sat Paul, resident of Moti Nagar, Ward No. 3, Tapa Mandi, Tehsil Tapa, Distt. Barnala, Punjab.
2. Mehak Goyal daughter of Jang Bahadur Goyal, resident of Moti Nagar, Ward No. 3, Tapa Mandi, Tehsil Tapa, Distt. Barnala, Punjab.
…Complainants
Versus
HDFC Ergo General Insurance Company Limited registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumabi-400020, through its Managing Director/Authorized Signatory.
…Opposite Party
Complaint Under Section 35 of the Consumer Protection Act, 2019.
Present: Sh. Gagandeep Garg Adv counsel for complainants.
Sh. Anuj Mohan Adv counsel for opposite party.
Quorum.-
1. Sh. Ashish Kumar Grover : President
2. Sh. Navdeep Kumar Garg : Member
(ORDER BY ASHISH KUMAR GROVER PRESIDENT):
The complainants have filed the present complaint under Section 35 of the Consumer Protection Act 2019 against HDFC Ergo General Insurance Company Limited registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumabi-400020, through its Managing Director/Authorized Signatory (in short the opposite party).
2. The facts leading to the present complaint are that the opposite party providing services of insurance to the customers/consumers being insurance company. The complainant No. 1 is the father of complainant No. 2. It is alleged that in the year of 2019 complainant No. 1 being main member purchased one family floater policy named as “Health Suraksha Policy (Silver Plan) from the opposite party for the period of 2019 – 2020 after paying the amount of Rs. 10,474/- for the said policy and opposite party issued one policy bearing No. 2825100248956902 to complainant No. 1 and complainant No. 2 in which the other members of the complainant’s family were insured upto the amount of Rs. 3 lacs for the period of year 2019-2020 (13.11.2019 to 12.11.2020) for the any type medical claim for any ailment or bodily problem. It is further alleged that the complainant No. 2 in the month of December 2019 suffered from problem of blur vision and on 28.12.2019 complainant No. 2 alongwith her father complainant No. 1 approached to the Vasu Eye Institute Bathinda, where doctor diagnose the problem and told to complainants that complainant No. 2 is suffering from disease Keratoconus (Blur vision Eye Sight Problem), thereafter complainant for best treatment approached to Punjab Lasik Laser Center Bathinda and Grewal Eye Institute Chandigarh and Dayanand Medical College & Hospital Ludhiana. Thereafter, on 21.2.2020 complainants approached Bhandari Starlife Eye Hospital & Blade Free Lasik Laser Centre, Ludhiana, where one minor operation of C3R Corneal Collagen Cross-Linking (Cornea Transplant) of complainant No. 2 was done by the doctors on 21.2.2020 and after operation the complainant No. 2 was discharged by the doctors and complainant No. 2 followed up the treatment till the prescription of Doctor and during the said treatment complainant’s expenditure was of Rs. 46,273/- for hospital charges, consultancy charges, medicine and tests of Lab. Thereafter, immediately on 26.2.2020 complainant No. 2 through her father complainant No. 1 approached the opposite party and e mailed all the bills, medical treatment bills, discharge summary, lab test etc., alongwith filled claim form and opposite party also generated the claim number i.e. RR-HS20-11163468 and assured that claim will be paid very soon to complainants by cheque at her address. Thereafter, complainants many times approached for policy benefits because as per requirements complainants have already submitted all the treatment history, medical bills, discharge summary and other relevant documents through e mail, but the opposite party did not pay any single money of medical treatment claim amount of above mentioned insurance policy. As such, all the facts stated above are clearly shows deficiency in service on the part of the opposite party. Hence, the present complaint is filed for seeking the following reliefs.-
- The opposite party may be directed to pay the amount of claim of Rs. 46,273/- with 18% interest from the date of discharge till realization.
- To pay Rs. 50,000/- on account of compensation for causing mental torture, agony and harassment to the complainant.
- Further, to pay Rs. 15,000/- as litigation expenses.
3. Upon notice of this complaint, the opposite party appeared and filed written version by taking preliminary submissions & objections that the complaint of the complainant is liable to be dismissed on the ground of claim being Pre-mature and the claim of the complainant was closed by the respondent on the ground of non submissions of the requisite documents as sought by the respondents. Further, the present complaint is bad for non-joinder and mis-joinder of parties. The opposite party had not acted in any arbitrary manner in denial of claim of the complainant. The complaint filed by the complainant does not fall within the definition of a consumer dispute under Consumer Protection Act. The complainant has got no cause of action and locus-standi to file the present complaint. This Commission has got no jurisdiction to try and decide the present complaint.
4. On merits, it is submitted that Jang Bahadur was insured for the period of 13.11.2019 dto 12.11.2020 under policy No. 2825 1002 4895 6902 000 for Health Suraksha Plan by the opposite party for benefits as detailed in Coverage Details of the policy subject to conditions and exclusions of the policy wordings and the policy are governed by the terms and conditions of the policy and the liability of the opposite party is limited to the insured perils occurring within the policy period subject to conditions and exceptions as mentioned in the terms and conditions of policy. It is further submitted that the complainant lodged the claim under the said policy in the name of Mehak Goyal daughter of Jang Bahadur Goyal which was registered as claim No. RR-HS20-11163468 and the said claim has been closed due to non-submission of the following documents:-
(i) Complete Claim Form
(ii) Original Final Bill with original payment receipt
(iii) Pre admission consulation papers related to present diagnosis, if any
(iv) NEFT details.
However, the complainant failed to submit the aforementioned documents. It is submitted that as per the terms and conditions of the policy, under Section 10 General Conditions, it is mentioned that the insured shall give all the documents, investigation reports etc., as may be reasonably required by the company, so that the claim may be processed. So, there is no deficiency in service on the part of opposite party and prayed for the dismissal of complaint.
5. Ld. Counsel for the complainants has suffered the statement on 19.9.2022 that I do not want to file any rejoinder on behalf of complainant and tendered into evidence affidavit of complainant Ex.C-1, copy of policy Ex.C-2 (containing 4 pages), copies of prescription slips Ex.C-3 & Ex.C-4, copy of OPD Card Ex.C-5 (containing 5 pages), copy of receipt Ex.C-6, copy of discharge slip Ex.C-7, copy of Indoor admission bill Ex.C-8, copy of prescription slip Ex.C-9, copy of Vision Test report dated 30.11.2019 Ex.C-10, copy of pharmacy bill Ex.C-11, copy of receipt dated 2.1.2020 Ex.C-12, copy of prescription slip dated 2.1.2020 Ex.C-13, copy of prescription for glasses as Ex.C-14, copy of claim status Ex.C-15, copy of adhaar card Ex.C-16, copy of claim form Ex.C-17 (containing 7 pages) and closed the evidence.
6. To rebut the case of the complainants the opposite party tendered into evidence affidavit of Manoj Parjapati Ex.O.P-1, copy of policy Ex.O.P-2, copy of terms and conditions Ex.O.P-3 (containing 16 pages), copy of incomplete claim form Ex.O.P-4, copy of discharge slip Ex.O.P-5 and closed the evidence.
7. We have heard the learned counsel for the parties and have gone through the record on the file. Written arguments filed by the opposite party.
8. The complainants have submitted in the complaint that they have purchased the health insurance policy from the opposite party for the period 13.11.2019 to 12.11.2020 and paid Rs 10,474/- and the copy of the policy is Ex.C-2. The complainants further alleged in the complaint that the complainant No. 2 suffered from problem of blur vision and they approached Vasu Eye Institute Bathinda and the complainant No. 2 diagnosed the problem of Keratoconus. Thereafter, the complainants approached Punjab Lasik Laser Center Bathinda and Grewal Eye Institute Chandigarh and Dayanand Medical College & Hospital Ludhiana, for the above said problem. Thereafter, the complainant No. 2 was approached Bhandari Starlife Hospital & Lasik Laser Centre, Ludhaina, where complainant No. 2 was operated. The complainants spent Rs. 46,273/- for hospital charges, consultancy charges, medicine and test bills. The complainants have produced the medical bill of Bhandari Starlife Hospital & Lasik Laser Centre, Ludhaina i.e. Ex.C-8 and other expenditure receipts as Ex.C-4, Ex.C-6, Ex.C-11 and Ex.C-12, which comes the total expenditure of Rs. 46,273/-. The complainants further alleged in the complaint that complainants approached the opposite party and emailed all the bills, medical treatment bills, discharge summary, lab test alongwith filled claim form and opposite party also generated the claim No. RR-HS20-11163468 and assured that claim will be paid very soon. The complainants further alleged that complainants many times approached the opposite party, but opposite party did not pay claim of medical treatment to the complainants.
9. On the other hand, the opposite party appeared and admitted the insurance policy. The opposite party has taken the specific objection that the complaint is pre-mature and claim of the complainants was closed by the opposite party on the ground of non submissions of the requisite documents as sought by the opposite party. The opposite party also alleged in the written version that the complainants have not submitted complete claim form, original final bill with original payment receipt, pre admission consultation papers related to present diagnosis, if any and NEFT details. Therefore, the claim of complainants was closed.
10. We have gone through the facts and evidence produced by both the parties carefully. The insurance policy in the present case is admitted by the opposite party. It is also admitted fact that the complainant No. 2 was insured under the policy in question. The complainants have produced the entire medical bills and receipts on the Court file as Ex. C-4, Ex.C-6, Ex.C-8, Ex.C-11 and Ex.C-12. The only ground taken by the opposite party for closing the claim is that the complainants have not submitted the required documents for processing the claim. On the other hand, the complainants have specifically mentioned in the complaint that the entire alleged documents was sent to the opposite party through email. The opposite party submitted that the complainants have not provided the original documents and receipts, but opposite party has failed to produce any letter vide which the opposite party demanded the alleged documents. The documents demanded by the opposite party have already been produced by the complainants on the Court file as Ex. C-4, Ex.C-6, Ex.C-8, Ex.C-11 and Ex.C-12. So, for not settling the genuine claim of the complainants there is clear cut deficiency in service & unfair trade practice on the part of the opposite party.
11. In view of the above discussion, the present complaint is partly allowed and the opposite party is directed to pay an amount of Rs. 46,273/- alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant No. 1. The opposite party is further directed to pay Rs. 10,000/- on account of mental agony and harassment and Rs. 5,000/- on account of litigation expenses to the complainant No. 1. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.
ANNOUNCED IN THE OPEN COMMISSION:
28th Day of June, 2024
(Ashish Kumar Grover)
President
(Navdeep Kumar Garg)
Member
