Maharashtra

Additional DCF, Mumbai(Suburban)

RBT/CC/12/15

YOGENDRA RAY - Complainant(s)

Versus

HDFC ERGO GENERAL INSURANCE CO. LTD, - Opp.Party(s)

L. S. YADAV

21 Mar 2017

ORDER

Addl. Consumer Disputes Redressal Forum, Mumbai Suburban District
Admin Bldg., 3rd floor, Nr. Chetana College, Bandra-East, Mumbai-51
 
Complaint Case No. RBT/CC/12/15
 
1. YOGENDRA RAY
FLAT NO. 304, BLDG NO. 30, THAKUR COMPLEX, OPP. ST. LAWRENCE HIGH SCHOOL, KANDIVALI-EAST, MUMBAI-101.
...........Complainant(s)
Versus
1. HDFC ERGO GENERAL INSURANCE CO. LTD,
6TH FLOOR, LEELA BUSINESS PARK, ANDHERI KURLA ROAD, ANDHERI-EAST, MUMBAI-59.
............Opp.Party(s)
 
BEFORE: 
 HON'BLE MR. S.D.MADAKE PRESIDENT
 HON'BLE MR. S.V.KALAL MEMBER
 
For the Complainant:
For the Opp. Party:
Dated : 21 Mar 2017
Final Order / Judgement

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.

  1. Copy of this order be sent to the both parties.
 
 
[HON'BLE MR. S.D.MADAKE]
PRESIDENT
 
[HON'BLE MR. S.V.KALAL]
MEMBER

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