BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FATEHABAD.
Complaint No.:11 of 2018.
Date of Instt.: 04.01.2018.
Date of Decision: 10.01.2019.
Bhagwant Rai son of Bihari Lal, resident of 223, Ward No. 10, Sanyas Ashram Road, Fatehabad, Tehsil and Distt. Fatehabad.
…Complainant.
Versus
HDFC ERGO General Insurance Company Limited, Steller IT Park,
Tower-I, 5th Floor, Sector-62, Noida-201301 through its Manager.
…Opposite Party.
Complaint U/s 12 of the Consumer Protection Act, 1986
Before: Sh .Raghbir Singh, President.
Sh. Jasvinder Singh, Member.
Dr. Rajni Goyat, Member.
Present: Sh.Kaushal Mehta, counsel for the complainant.
Sh. U.K. Gera, counsel for the opposite party.
ORDER:
The present complaint under Section 12 of Consumer Protection Act, 1986 has been filed by the complainant against the Opposite Party (hereinafter referred as OP) with the averments that he purchased a medi-claim policy no.2825100136680200 from the OP and thereby getting insured the health of himself and his wife namely, Mamta Rani and the policy was valid from 23.8.2016 getting coverage of hospitalization and medical expenses amounting to Rs. 15 lakhs. The complainant had also made payment of the premium and an ID was also issued by the OP to the complainant. Therefore, the complainant is consumer of the OP as defined in the Consumer Protection Act, 1986.
2. It is further submitted that the complainant sustained injuries on his left knee and the left femur of the complainant was fractured, for which the complainant was admitted in Chawla Nursing Home, Hisar on 28.11.2016 for taking treatment and the complainant was operated on 29.11.2016 and discharged from the hospital on 3.12.2016. Intimation regarding the same was given to the OP by the complainant and Claim Reimbursement Form and other relevant documents were also handed over to the OP and it was assured to the complainant that his claim will be reimbursed within a short period. It is further submitted that along-with relevant documents the complainant submitted a bill of Rs. 1,50,000/- and at that time it was assured that his insurance claim will be settled very soon, but till date the claim amount has not been paid to the complainant by the OP despite requests made by the complainant several times. Finally vide letter dated 5.9.2017, it was intimated by the OP that his insurance claim has been closed. It is further submitted that the insurance claim of the complainant has been closed by the OP on false and baseless grounds which is against the terms and conditions of the medi-claim policy between the complainant and the OP. The abovesaid act on the part of OP amounts to deficiency and as such the complainant is entitled for compensation worth Rs. 40,000/- from OP on account of mental agony, harassment and humiliation. The complainant has further prayed that the OP may be directed for making a payment of Rs. 1,50,000/- as medical bills along-with compensation of Rs. 40,000/- and litigation charges of Rs. 5,000. Hence, the present complaint.
3. On being served OP appeared through counsel and resisted the complaint by filing a written reply wherein various preliminary objections with regard to maintainability, cause of action, locus standi and territorial jurisdiction etc. have been raised.
4. In reply on merits, it is admitted that the complainant was insured with the OP, but the policy of insurance was issued subject to terms and conditions of the policy. It is further submitted that on receipt of intimation along-with claim papers the complainant was asked to submit certain original papers and such as bills of treatment, preoperative X-Ray film and X-Ray report in support of fracture of neck of femur, treating doctor certificate vide letters dated 21.3.2017, 5.4.2017, 20.4.2017, 28.5.2017 and 21.8.2017. However, the complainant did not submit the abovesaid documents for the reasons best known to him. It is further submitted that the complainant did not provide the abovementioned documents which were necessary for the settlement of the claim. Therefore, the claim of the complainant has not been repudiated by the OP and the file of the complainant has been closed as he did not provide the required documents. Therefore, there is no deficiency on the part of OP in rendering service to the complainant and as such the present complaint is liable to be dismissed.
5. The learned counsel for the complainant tendered in evidence affidavit of the complainant as Exhibit CW1/A along-with the documents as Annexure C-1 to Annexure C-15 and the document as Exhibit C-1. On the other hand, the learned counsel for the OP tendered in evidence affidavit of Pankaj Kumar as Annexure R-1 in support of the case of the OP and closed the evidence.
6. We have duly considered the arguments advanced by learned counsel for the parties and have also perused the entire material placed on record. Undisputedly, the complainant had purchased a medi-claim policy bearing no. 2825100136680200 from the OP and thereby insured the health of himself and his wife valid from 23.8.2016. This fact is very much established from the document Annexure C-1. From the document Exhibit C-1 issued by Chawla Nursing Home, Model Town, Hisar, it is also established that the complainant was admitted in the abovesaid hospital on 28.11.2016 for treatment of Fracture Neek Femur LT. From the abovesaid document, it is also established that he was operated in the abovesaid hospital on 29.11.2016 and was discharged on 3.12.2016. On the back side of the document Exhibit C-1 X-ray films of the knee have been displayed. From Annexure C-5 to Annexure C-11, it is also established that the complainant has made payment of medicines purchased from Sandeep Medical Hall inside Chawla Nursing Home, Hisar. From perusal of Annexure C-12, it is also established that the complainant had purchased Uncemented total HIP Replacement Large Head on 29.11.2016 from R.K. Viklang Kendra and Surgical House, Shop No. 89 Ganesh Market, Hisar for an amount of Rs. 84,200/-. From Annexure C-14, it is also established that the complainant had made a payment of Rs. 41,100/- to Chawla Nursing Home, Hisar for treatment, admission fee, room rent and other charges. Furthermore, there is no dispute to the fact that the complainant lodged the claim in this regard with the OP. The grouse of the complainant is that despite submitting all the relevant documents as required the OP did not honuor his claim and kept the matter pending on one pretext or the other.
7. Per contra, the stand of the OP is that relevant documents i.e. X-ray film before operation and after operation of fracture of Neek Femur and treating doctor certificate has not been furnished by the complainant. Therefore, the case of the complainant could not be finalized and as such the same has been closed. It is further the case of the OP that the case of the complainant is pre-mature and as such the same deserves dismissal.
8. After scrutinizing all the documents placed on case file by the complainant as discussed above, we are of the considered opinion that, it is abundantly established on file that the complainant has already submitted all the relevant documents to the OP for finalization of his claim which includes date of admission, date of discharge, name of treating doctor, date of operation and the body part which have been operated and the treatment given and X-ray films. We are of the considered opinion that the requisite documents has already been submitted by the complainant to OP and the matter is being delayed unnecessarily by the OP.
9. In view of the position as discussed above that the complainant has been able to prove deficiency on the part of OP in rendering service to him. The present complaint is accordingly allowed and the OP is directed for making a payment of Rs. 1,50,000/- to the complainant for the expenses incurred by him in operation and treatment of his fracture. The OP is further directed for making a payment of Rs. 5,000/- as compensation and litigation charges to the complainant. This order be complied with within a period of 30 days, otherwise the amount shall carry an interest at the rate of 8% per annum for the default period. Copy of this order be supplied to the parties free of costs. File be consigned to record room after due compliance.
Announced in open Forum. Dated:10.01.2019
(Raghbir Singh)
President
District Consumer Disputes
Redressal Fourm,Fatehabad
( Rajni Goyat) (Jasvinder Singh)
Member Member
