PRESENT
Complainant in person present.
Opponent by Adv.Smt. Bhavani Bhatt present.
ORDER
(Per- Mr. S. D. MADAKE, Hon’ble President)
1. The complainant has taken a HDFC Ergo Health Insurance policy of opponent through HDFC bank credit card. The period of policy was 5.6.2010 to 4.6.2011.
2. The complainant was admitted at Visakhapathnam in Satyam intensive care unit during insurance period, in Sept. 2010. He incurred expenses for medicines and hospital bill.
3. The complainant alleged that, opponent failed to settle the claim. He paid premium of Rs.9,613/- through credit card of HDFC.
4. In para 7 of complaint, he alleged about deficiency of service on the part of HDFC bank, regarding use of musle power by said bank i.e. HDFC.
5. The complainant prayed for direction to opponent to pay hospital and medical bills, cost and compensation for mental agony to the amount of Rs.1,00,000/-.
6. The complaint was admitted on 18.1.2012 . The opponent filed written statement on 30.11.2012 stating that complaint is false, frivolous , and vexatious.
7. The opponent alleged in para 8 the stated that complainant never intimated any claim nor he submitted any claim form for settlement of claim as required under the policy and law.
8. The opponent stated in para 10 that complainant addressed letter dated 14.6.2011 to the bank which was replied by bank on 28.6.2011 . There is no any material to show complainant intimated any claim promptly within parameters of medi-claim policy.
9. The complainant filed on record the Insurance policy, letter dated 9.6.2010 from HDFC bank, letter dated 14.62011 sent to bank , reply of HDFC bank dated 28.6.2011, Hospital bills, timesheets, blood reports dated 5.9.2010, discharge letter etc.
10. The documents filed on record clearly indicate that complainant has taken insurance policy of opponent and the complainant was admitted in the hospital during the insurance period. The medical bills, prescriptions, reports of medical examination, and papers relating to treatment are filed on record.
11. The opponent has not disputed about policy, however stated that complainant has not intimated nor submitted any claim form for settlement of claim. The complainant submitted that he tried to contact opp. for the claim, however there was no response.
12. The main grievance of complainant is against the HDFC bank , on the allegation of using threatening words and musle power for recovery of unjustified amount of loan. However as the present case is against Insurance company which is distinct separate legal entity.
13. The complainant has not stated in complaint regarding the details of claim submitted to opp. and same was not considered. He has not filed any documents on record regarding claim form.
14. The complainant was expected to fill the claim form in the format prescribed as he is having experience and served in different countries.
15. We are of the opinion that, considering the bills are filed on record and claim is as per policy, we direct opp. to pay the bills incurred by complainant for hospitalization and treatment.
16. We have perused evidence affidavit of complainant dated 1.2.2013 stating that he incurred Rs.4,705/- towards hospital and medicine. We have perused receipts which corroborate the contents of affidavit.
17. The medical expenses were incurred in Sept.2010, however opp. has not paid the same till this date. The opp. has not proved that the bills are not as per policy by filing evidence.
18. The opponent is liable to indemnify the complainant for the expenses incurred for hospitalization and Medical bills.
19. The complainant claimed compensation of Rs. 1,00,000/- for mental agony. He has not justified the said claim. He has not filed claim form and there is no evidence to show that opp. intentionally denied claim. He is entitle for reasonable compensation of Rs.5,000/- and cost of Rs.5,000/-.
20. In the result , we pass the following order.
ORDER
1. RBT/CC/15/2012 is party allowed.
2. HDFC ERGO GENERAL INSURANCE company is directed to
Pay Rs.4,700/- with interest @ 9 % p.a. from the date of filing of
Complaint till payment.
3. The opponent is directed to pay Rs.5,000/- as compensation for
mental agony and Rs.5,000/- as cost to complainant.
- Copy of this order be sent to the both parties.
