DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.
Complaint No. 201
Instituted on: 11.05.2017
Decided on: 06.09.2017
Charanjit Sharma aged about 58 years son of Shri Devi Dayal Sharma, resident of Near Nagar Council Office, Bhawanigarh, Tehsil and Distt. Sangrur.
…Complainant
Versus
1. HDFC Ergo General Insurance Company Limited, Corresponding Office Stellar IT Park, Tower-1, 5th Floor, C-25, Sector -62, Noida, 201301 through its authorised signatory.
2. HDFC Ergo General Insurance Company Limited, Registered and Corporate Office 1st Floor, 165-166, Backbay Reclamation, H.T. Parekh Marg, Churchgate, Mumbai400 020 through its Authorized Signatory.
..Opposite parties.
For the complainant : Shri S.P.Sharma, Adv.
For Opp.parties : Shri Sanjeev Goyal, Adv.
Quorum: Sukhpal Singh Gill, President
Sarita Garg, Member
Order by : Sukhpal Singh Gill, President.
1. Shri Charanjit Sharma, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant availed the services of the OPs by getting himself insured under health/medical policy number 50271735 for the period from 8.6.2014 to 7.6.2015 by paying the requisite premium. Further case of the complainant is that he faced unsteadiness of gait for about three months and difficulty in standing erect and broad based gait, as such the complainant took treatment on 24.10.2014 from Dr. Gurjinder Pal Singh, Bhatia Neuro Centre, Patiala and MRI scan and brain report was done by Delta MRI and CT Scan Centre, Patiala. Further case of the complainant is that on 5.11.2014, he approached Fortis Hospital Mohali for his treatment and consultation with the doctors. The MRI test was done by the doctors from where the complainant got his treatment for a few days and medicine was prescribed by the doctors and thereafter the complainant was admitted in Gupta Hospital on 27.11.2014 to 3.12.2014 and during the hospitalization, the doctor gave the injections and medicines to the complainant, which were purchased by the complainant vide bill number for Rs.3,21,440/- from Kartik Medicose, Bhawanigarh. It is further averred that thereafter the complainant was again admitted on 29.12.2014 in the PGI Hospital, Chandigarh, where the tests were also conducted and again the complainant was admitted in PGI Chandigarh from 12.1.2015 to 31.1.2015. Thereafter, he lodged the claim with the OPs for payment, but the OPs issued letter dated 21.2.2015 to the complainant demanding some documents, which were submitted to the OPs by the complainant. The Ops again issued letters dated 8.3.2015 and 23.3.2015, which the complainant did not receive as he was admitted in Medanta Global Health Pvt. Ltd. New Delhi and after discharge from the hospital, the complainant submitted all the documents to the OPs, but the grievance of the complainant is that the Ops did not pay the insurance claim amount of Rs.3,21,440/-, despite serving legal notice upon the Ops. Thus, alleging deficiency in service on the part of the Ops, the complainant has prayed that the Ops be directed to pay to the complainant the claim amount of Rs.3,21,440/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.
2. In reply of the complaint filed by the Ops, preliminary objections are taken up on the grounds that the complaint is false, frivolous, vague and vexatious in nature and that the complainant is himself guilty for his own act and conduct for not providing the documents sought for vide letters dated 21.2.2015, 8.3.2015 and 23.3.2015 including the certificate from treating doctor of PGI Chandigarh confirming cause of cerebellitis, that the complainant has not impleaded Apollo Munich Health Insurance Co Ltd., that the complaint is not maintainable and that the complaint being frivolous and vexatious should be dismissed with special costs. On merits, it is admitted that the complainant took the insurance policy in question for Rs.2,00,000/-. It is admitted that the complainant lodged the claim with the OPs as he was suffering from the disease of Occlusion and Stenosis of cerebeller arteries with date of admission as 27.11.2014 and discharge on 3.12.2014. It is stated that the complainant did not submit the required documents to the OPs for settlement of the claim and further it is stated that the complainant did not submit any documents as stated in the complaint. However, the other allegations levelled in the complaint have been denied in toto.
3. The learned counsel for the complainant has produced Ex.C-1 affidavit, Ex.C-2 to Ex.C-33 copies of documents and closed evidence. On the other hand, the learned counsel for the OPs has produced Ex.OP-1 affidavit, Ex.OP-2 to Ex.OP-7 copies of documents and closed evidence.
4. We have carefully perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits part acceptance, for these reasons.
5. It is an admitted fact between the parties that the complainant availed the services of the OPs by getting a medical insurance policy number 50271735 for Rs.2,00,000/- from the OPs. It is also not in dispute that the complainant took treatment from various hospitals including Bhatia Neuro Center, Fortis Hospital, PGI Hospital, Chandigarh and submitted the bills to the tune of Rs.3,21,440/- to the OPs. Now, the grievance of the complainant is that the Ops have not paid the amount nor settled the claim, as such has prayed that the Ops be directed to pay to the complainant the alleged amount. On the other hand, the learned counsel for the Ops has contended vehemently that the complainant has not submitted the required documents to the OPs, such as purchase invoice of the injections, infusion details, PET scan report, certificates from Dr. Gurjinder Pal Singh, report of MRI Plain and MRI contrast, consultation papers of Fortis hospital as well as certificate from treating doctor of PGI, Chandigarh confirming cause of cerebellitis and consultation papers of doctors from whom insured is taking treatment for DM and HTN since last 20 years. The case of the complainant is that he has already submitted the documents to the Ops and has further produced on record during the present proceedings as Ex.C-2 to Ex.C-36, a copy of which has also been provided to the OPs. In the circumstances of the case, we feel that ends of justice would be met if the OPs are directed to get the medical opinion of the board of doctors duly prescribed by the OPs and thereafter to settle the claim of the complainant.
6. Accordingly, in view of our above discussion, we allow the complaint partly and direct the Ops to constitute a board of doctors to check the medical record of the complainant and to give opinion about the case of the complainant on the basis of medical record of the complainant within a period of 45 days from today. Thereafter the OPs shall settle the claim and intimate the complainant their decision by registered post within a period of 15 days, failing which the Ops shall be liable to pay to the complainant the claim amount of Rs.2,00,000/-. The OPs shall also pay to the complainant an amount of Rs.10,000/- in lieu of litigation expenses.
7. A copy of this order be issued to the parties free of cost. File be consigned to records.
Pronounced.
September 6, 2017.
(Sukhpal Singh Gill)
President
(Sarita Garg)
Member
