BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 19 of 2021
Date of Institution : 29.01.2021.
Date of Decision : 06.11.2024.
Deepak Garg son of Shri Om Parkash, resident of Shop No. 109, New Grain Market, Kalanwali, Tehsil Kalanwali, District Sirsa (Haryana).
……Complainant.
Versus.
1. HDFC Ergo General Insurance Company Ltd., C/o HDFC Bank Ltd., Old Thana Road, Kalanwali, Tehsil Kalanwali, District Sirsa through its Branch Manager.
2. HDFC Ergo General Insurance Company Ltd. 5th Floor, Tower 1, Staller IT Park, C-25, Sector 62, NOIDA- 201 301 through its Manager/ Authorized Signatory.
3. HDFC Bank Ltd., Kalanwali Branch, District Sirsa, through its Branch Manager.
...…Opposite parties.
Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR …………PRESIDENT
MRS.SUKHDEEP KAUR………………MEMBER.
SH. OM PARKASH TUTEJA…………..MEMBER
Present: Sh. Kamal Garg, Advocate for complainant.
Sh. H.S. Raghav, Advocate for opposite parties no.1 and 2.
Opposite party no.3 already exparte.
ORDER
The present complaint has been filed by complainant under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred as OPs).
2. In brief, the case of the complainant is that complainant had purchased health insurance policy bearing No. 2828 1001 3168 0401 000 from ops for the sum assured amount of Rs.3,00,000/- for the period 01.08.2018 to 31.07.2020 and complainant paid a sum of Rs.7563/- as insurance premium to the ops. That complainant had developed abdomen pain and he was diagnosed with kidney stones and he was got admitted in Fortis Hospital, Mohali on 13.02.2020 where he was operated upon and was discharged on 16.02.2020. A sum of Rs.2,33,854/- was paid by complainant to the above said Hospital for operation and other hospital expenses. It is further averred that thereafter complainant lodged his claim with the ops and supplied all the required documents and a sum of Rs.2,22,840/- was paid to the complainant after deducting a sum of Rs.11,014/- without assigning any reason. The complainant had lodged a protest with the ops for making less payment of Rs.11,014/- but the ops did not give any response to the same. That thereafter stenting applied to complainant was to be removed and thus complainant incurred a sum of Rs.15,483/- on the removal of the stents. It is further averred that complainant also lodged his claim for the above amount of Rs.15,483/- but the same has not been paid to him till today. The complainant is legally entitled to recover a sum of Rs.11,014/- plus Rs.15,483/- plus Rs.1000/- as consultation fee, Rs.350/- as diagnosis charges and Rs.4000/- as travelling expenses totaling Rs.31,847/- from ops alongwith interest. That complainant approached the ops and requested them to make payment of aforesaid amount of Rs.31,847/- alongwith interest but ops did not pay any heed to the same and ultimately complainant got served a legal notice to the ops on 04.12.2020 but to no effect and as such ops have caused deficiency in service and unnecessary harassment to the complainant and adopted unfair trade practice. Hence, this complaint.
3. On notice, op no.1 appeared and filed written version raising certain preliminary objections. It is submitted that op received a cashless claim of complainant from Fortis Heart Hospital which was registered vide cashless claim ID RC-HS19-10817217 and after receiving all the cashless claim documents, the cashless was approved by the op and out of the total claim amount of Rs.2,33,854/- op settled claim amount of Rs.2,24,154/-. The rest of the amount of Rs.9700/- was not payable as per IRDAI Guidelines and agreement done with the Hospital. It is further submitted that it is denied that complainant filed any reimbursement claim for an amount of Rs.15,483/- and complaint of complainant is pre-mature as complainant has not reported any reimbursement claim under the said policy to the answering op. Therefore, answering op was/ is unable to review and decide upon the admissibility/ non admissibility of the said claim of complainant in absence of documentary evidence pertaining to the said claim. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
4. Op no.2 also filed separate written version and resisted the complaint of complainant on similar grounds as of op no.1.
5. Op no.3 did not appear despite delivery of notice and as none appeared on behalf of op no.3, therefore, op no.3 was proceeded against exparte.
6. The complainant in evidence has tendered his affidavit Ex.C1 and documents Ex.C2 to Ex.C16.
7. On the other hand, ops no.1 and 2 have tendered affidavits of Sh. Vivek Yadav, Senior Manager as Ex.R1 and Ex.R2 and documents Ex.R3 and Ex.R4.
8. We have heard learned counsel for the parties and have gone through the case file.
9. Admittedly the complainant had purchased health insurance policy from the ops for the period 1.8.2018 to 31.07.2020 for the sum assured amount of Rs.3,00,000/-. According to complainant during the period of policy in question he remained admitted in Fortis Hospital, Mohali from 13.02.2020 where he was operated for kidney stones and was discharged on 16.02.2020 and he spent an amount of Rs.2,33,854/- on his treatment. In so far as claim of complainant for an amount of Rs.2,33,854/- is concerned, the ops have already settled the claim of complainant for an amount of Rs.2,24,154/- and according to ops remaining amount of Rs.9700/- was not payable as per IRDAI guidelines and agreement with the Hospital and as such same does not require any interference by this Commission. In so far as claim of complainant for an amount of Rs.15,483/- regarding removal of stent is concerned, the ops no.1 and 2 have categorically asserted that no such claim was ever lodged with them and op no.1 with clear and bonafide intention filed an application for sending the matter to Mediation Cell on the ground that op has not received any reimbursement claim from the complainant pertaining to the removal of stent for an amount of Rs.15,483/- and that op is ready and willing to review any claim to be submitted by complainant including the removal of stent as per terms and conditions of the policy and complainant may be directed to file reimbursement claim with the op. Though complainant has placed on file bill of the amount of Rs.15,483/- of the Fortis Hospital, Mohali as Ex.C9 but there is nothing on file to prove the fact that complainant ever lodged any claim of said amount with the ops no.1 and 2. So, it can be said that complaint in this regard is pre-mature. As such complainant has to lodge his claim in this regard with ops no.1 and 2 and thereafter ops no.1 and 2 will settle and pay the claim to the complainant.
10. In view of our above discussion, we partly allow the present complaint and direct the complainant to lodge his claim of the amount of Rs.15,483/- with the ops no.1 and 2 within a period of 30 days from the date of receipt of copy of this order and thereafter ops no.1 and 2 will settle and pay the claim to the complainant as per terms and conditions of the policy within further period of 30 days. However, keeping in view the facts and circumstances of present case, the parties are left to bear their own costs. It is further made clear that in case ops no.1 and 2 do not settle and pay the claim of complainant despite lodging of the claim with them by the complainant, then in that eventuality the complainant will be entitled to receive the said whole claim amount of Rs.15,483/- alongwith interest at the rate of @ 6% per annum from the date of lodging of claim by the complainant till actual realization. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced: Member Member President,
Dated: 06.11.2024. District Consumer Disputes
Redressal Commission, Sirsa.
