DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, CAMP COURT, AT AMRITSAR, PUNJAB.
Complaint Case No : RBT/CC/2018/406.
Date of Institution : 01.06.2018/29.11.2021.
Date of Decision : 22.06.2022.
Sh. Pardeep Singh son of Sh. Jaswinder Singh resident of Harsha Chhina, Kukkaranwala, Near Bijli Ghar, Tehsil Ajnala, District Amritsar.
…Complainant Versus
1.H.D.F.C ERGO General Insurance Company Limited Registered and Corporate office. HDFC House, 1st Floor, 165-166, Backbaty Reclamation. H.T. Parekh Marg, Churchgate, Mumbai-400020 through its Director/Manager/Authorized Signatory.
2.H.D.F.C ERGO General Insurance Company Limited, H.D.F.C Bank Limited, Khasra No. 355-356, Gopal Nagar, Majitha Road, Amritsar, through its Divisional Manager/Branch Manager.
…Opposite Parties
Complaint Under Section 12 & 13 of Consumer Protection Act, 1986. As Amended Upto Date.
Present: Sh. Jugraj Singh Adv counsel for complainant.
Sh. R.P. Singh Adv counsel for opposite parties.
Quorum:-
1. Sh. Ashish Kumar Grover : President
2.Smt. Urmila Kumari : Member
(ORDER BY ASHISH KUMAR GROVER, PRESIDENT):
1. The present complaint has been received by transfer from District Consumer Commission, Amritsar in compliance of the order dated 26.11.2021 of the Hon'ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh. The complainants have filed the present complaint Under Section 12 & 13 of the Consumer Protection Act, 1986 (as amended upto date) against the Amritsar Improvement Trust (hereinafter referred as opposite party)
2. Brief facts of the case are that the complainant is having account No. 15801930000194 in opposite party No. 2 Bank and the complainant is dealing with the opposite party No. 2 bank branch since long. Employee of the opposite party No. 2 requested the complainant to take insurance policy, as such the complainant purchased Health Suraksha Policy from the insurance company in his name and in the name of his daughter Hazel Kaur bearing policy No. 2825100104138700000. The said insurance policy is w.e.f. 29.2.2016 to 28.2.2017 for the sum insured Rs. 3,00,000/- and in this regard the opposite party No. 2 deducted Rs. 5,586/- from the account of complainant being premium.
3. It is further alleged that lateron the complainant suffered from severe chest pain and admitted in IVY Hospital of Super Specialty Health Care, Airport Road, Amritsar on 11.1.2017 and the complainant was discharged from the hospital on 12.1.2017 and on his treatment the complainant spent Rs. 36,530/-. After the discharging from the hospital the complainant approached the opposite party No. 2 to pay him the insurance amount as per terms of the said policy. The opposite party No. 2 told the complainant to produce the certificate of concerned doctor of the above said hospital regarding the admission and regarding his disease. The complainant took the said certificate from IVY hospital on 23.2.2017 and produced the same before the opposite party No. 2 and complainant requested to pay the medical bills as per certificate issued by the IVY hospital, but the opposite party No. 2 delaying the matter on one pretext or the other and flatly refused to pay the insurance amount to the complainant. Thereafter, the complainant served a legal notice dated 7.2.2018 upon the opposite parties through registered post for payment of medical bills, but of no use. Due to the above said act of the opposite party the complainant suffered mental agony and harassment which amounts to deficiency in service and unfair trade practice on the part of opposite party. Hence, the present complaint is filed for seeking the following reliefs.-
i) To pay a sum of Rs. 36,360/- alongwith interest @ 18% per annum from the date of invoice till final payment.
ii) To pay Rs. 50,000/- on account of mental agony and harassment and Rs. 5,500/- on account of litigation expenses.
4. Upon notice of this complaint, the opposite parties appeared and filed written version by taking preliminary objections interalia on the grounds that after receiving the claim intimation from the complainant, letters dated 25.1.2017, 9.2.2017 were sent to the complainant and sought documents mentioned in the letters, but neither the documents nor information was provided, therefore vide letter dated 11.3.2017 the claim was considered as closed and due intimation of the same was sent to the complainant. The present complaint is premature. On merits, it is admitted that the complainant was insured under the Health Suraksha Policy No. 2825100104138700000 valid from 29.2.2016 to 28.2.2017 for the sum insured Rs. 3,00,000/-. It is submitted that opposite parties received a reimbursement claim alongwith the documents on 21.1.2017 and after scrutinizing the claim form and papers the opposite parties found that the documents were insufficient to settle the claim amount. Therefore, vide letter dated 25.1.2017 opposite parties requested the complainant to provide the following documents:-
(i)Exact cause and duration of said ailments since when first symptoms appear certified by treating doctors alongwith first consultation papers.
(ii)Original pre numbered final hospital bill with detail break up.
(iii)All past treatment records.
(iv)Certificate from treating doctors positive sign for recommendation CAG.
The complainant has failed to provide the above mentioned documents to the opposite parties till date and the claim of the complainant has never been rejected but has been “closed” due to non-receipt of documents from the complainant. As such, there is no deficiency in service on their part and prayed for the dismissal of complaint.
5. In support of his case the complainant at the time of filing the complaint has filed his affidavit Ex.CW1/A and documents Ex.C-1 to Ex.C-8.
6. On the other hand, to rebut the case of the complainant the opposite parties at the time of filing the written version filed affidavit of Sh. Pankaj Kumar Manager Legal Claims Ex.O.P1/1 and documents Ex.O.P1/2 to Ex.O.P1/7.
7. We have heard the Ld. Counsel for the parties and have gone through the documents placed on record by the parties.
8. It is not disputed between the parties that the complainant purchased Health Suraksha Policy from the insurance company in his name and in the name of his daughter bearing policy No. 2825100104138700000 and the policy was valid from 29.2.2016 to 28.2.2017 for the sum insured Rs. 3,00,000/- i.e. Ex.C-4. It is also not disputed that the complainant suffered from severe chest pain and admitted in IVY Hospital of Super Specialty Health Care, Airport Road, Amritsar on 11.1.2017 and was discharged from the hospital on 12.1.2017 i.e. Ex.C-6. Ld. Counsel for complainant argued that the complainant on his treatment has spent Rs. 36,530/- and being insurer the complainant approached the opposite party No. 2 for reimbursement of above said medical bill Ex.C-4. Ld. Counsel for the complainant further argued that on the advice of opposite party No. 2 the complainant took the above said medical certificate from IVY hospital on 23.2.2017 i.e. Ex.C-8. Ld. Counsel for complainant also argued that all the required documents alongwith medical bill and certificate of concerned doctor have been submitted to the opposite party to settle the claim. But the opposite parties inspite of deciding the genuine claim of the complainant linger on the matter on one pretext or the other without any reason. On the other hand, Ld. Counsel for opposite parties argued that vide letters dated 25.1.2017 & 9.2.2017 i.e. Ex.O.P1/5 & Ex.O.P1/6 the complainant was requested to submit the required documents for the settlement of claim. But till date the complainant has failed to submit the required documents with the opposite parties, therefore vide letter dated 11.3.2017 Ex.O.P1/7 the claim was considered as 'closed'. From the perusal of the file it is established that the complainant has purchased the above said policy Ex.C-4 from the opposite parties which was valid from 29.2.2016 to 28.2.2017 for the sum insured Rs. 3,00,000/- and during the policy period the complainant suffered severe chest pain and was admitted in IVY Hospital and spent Rs. 36,530/- vide bill Ex.C-6 and lodged the claim with the opposite parties for the reimbursement of above said medical bill. But the opposite parties did not settle the claim and rejected the claim as “closed” without any valid reason. The complainant has also placed on record certificate of treated doctor i.e. Ex.C-8 in which it is mentioned that;-
“Patient named Mr. Pardeep Singh, 37 years old male had history of severe retrosternal chest pain with approximately 12 hours duration. Hereby cause of pain was Gastritis Cardiac evaluation was normal”.
Therefore, it is proved on the file that the complainant has suffered severe retrosternal chest pain as per certificate of treated doctor Ex.C-8 and was admitted in the IVY hospital on 11.1.2017 and was discharged on 12.1.2017 and spent Rs. 36,530/- as per hospital bill Ex.C-6. But the opposite parties without any valid ground considered the claim of the complainant as “closed” on the basis of letters Ex.O.P1/5 & Ex.O.P1/6 which was sent to the complainant for submitting the documents but the opposite parties have failed to place on record the postal receipts of the above said letters to prove that the same were sent to the complainant.
9. In view of the above discussion, the present complaint is partly allowed against the opposite parties and the opposite parties are directed to pay Rs. 36,530/- alongwith interest @ 6% per annum from the date of filing the present complaint. The opposite parties are further directed to pay Rs. 5,000/- on account of mental agony and harassment to the complainant and Rs. 3,300/- on account of litigation expenses. Compliance of the 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 will be supplied to the parties free of costs by the District Consumer Commission, Amritsar as per rules. File be sent back to District Consumer Commission, Amritsar.
ANNOUNCED IN THE OPEN COMMISSION:
22nd Day of June, 2022
(Ashish Kumar Grover)
President
(Urmila Kumari)
Member
