Haryana

Bhiwani

CC/243/2022

Shyam Parkash - Complainant(s)

Versus

HUDA - Opp.Party(s)

Ram niwas rohilla

20 Nov 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BHIWANI.

 

                                                             Consumer Complaint No. : 19 of 2021

                                                        Date of Institution           : 21.01.2021

                                                                  Date of order                  : 20.11.2023

 

Shashi Ranjan son of Sh. Balbir Singh R/o village Bamla-I, Tehsil and District Bhiwani, presently residing at Gali No.10, Near Garima Garden, Tosham Bye Pass, Bhiwani, Tehsil and District Bhiwani.

  

           ……Complainant.

 

Versus

 

1. Religare Health Insurance Company Ltd., registered office: 5^th Floor, Chawla House, Nehru Place, New Delhi-110019 through its Chairman/M.D.

 

2. Religare Health Insurance Company Ltd., Unit 604, 605,606,607, 6^th Floor, Tower-C, Unitech Cyber Park, Sector-39, Gurugram-122001 through its Manager.

…… Opposite Parties.

 

COMPLAINT U/S 35 OF CONSUMER PROECTION ACT, 2019.

 

BEFORE:       Hon’ble Mrs. Saroj Bala Bohra, Presiding Member.

  Hon’ble Ms. Shashi Kiran Panwar, Member.

 

Present:-        Complainant alongwith Sh. S.K.Mehra, Advocate.

Sh. Rajesh Kumar Kaushik, Advocate assisted by Sh. Sudhir Kumar, Advocate for OPs.

 

ORDER:

 

Saroj Bala Bohra, Presiding Member:

 

1.                 In brief, facts of this case are that complainant purchased a health insurance policy no.13411993 from OP No.2 by paying Rs.11,371/- on 12.12.2018 for himself and his wife Mukesh Rani, for a term of one year commencing from 12.12.2018 to 11.12.2019. On 15.02.2019 at about 9:00 a.m., complainant fell down from his scooty Activa bearing regn. No.HR 16U 7312 and got fractured in his left leg below knee.  He was admitted in Civil Hospital, Bhiwani from 15.02.2019 to 19.02.2019 for treatment and operation, iron rod was fitted in the leg. Complainant incurred Rs.13,020/- for the said rod.  Complainant lodged claim with OPs alongwith relevant documents qua the said amount but the claim was not released rather it was rejected by OPs vide letter dated 04.03.2020. The act & conduct of OPs, as per complainant, amounts to deficiency in service. So, legal notice was served upon the OPs but of no avail Hence, the present complaint has been preferred alleging deficiency in service on the part of Ops resulting into monetary loss as well as mental and physical harassment with a prayer for issuance of directions to OPs to pay Rs.13,020/- which incurred on treatment alongwith interest @ 24% per annum from the date of accident till actual payment, Rs.10,000/- as compensation for harassment, Rs.5000/- as litigation expenses and Rs.11,000/- as counsel fee.  Any other relief to which this Commission deems fit has also been sought.

2.                 OPs appeared through counsel and tendered reply raising preliminary objections that the present complaint is not maintainable; that this Commission has no jurisdiction to entertain this complaint, that complainant has no locus standi to file the present complaint and that complainant has concealment of true facts. On merits, it is submitted that OP received the claim of complainant on 06.11.2019.  As all the required documents were not submitted by the complainant, therefore, a deficiency letter dated 11.11.2019 was sent to him for submitting investigation report supporting diagnosis, detail original final bill, pre & post-operative x-ray, treating doctor’s certificate for alcohol/any other drug abuse etc. but the same were not submitted despite issuing reminder in this regard, therefore, the claim was closed vide letter dated 29.02.2020. In the end, prayer for dismissal of complaint has been made.

3.                 In evidence of complainant, documents Annexure C-1 to Annexure C-11 were tendered and then closed the evidence.

4.                 In evidence of OPs, affidavit Ex. RW1/A of Sh. Tejinder Singh, on behalf of OP alongwith documents Annexure R-1 to Annexure R-9 were filed and closed the evidence.

5.                 We have heard learned counsel for the parties and perused the record minutely.  Written arguments on behalf of complainant was filed.

6.                 The case of complainant is that during the period of insurance policy, complainant met with an accident and got operated at Civil Hospital, Bhiwani and spent a sum of Rs.13,020/- but the OP insurance company did not reimburse the same rather repudiated the claim of complainant vide letter Annexure R-7.  Ld. Counsel for complainant has argued that despite submitted all the relevant documents OP company has rejected the claim of complainant and  due to such act & conduct of OPs, complainant has to suffer monetary loss as well as mental and physical harassment. In support of his contention, the counsel has placed reliance on case law delivered by Hon’ble Punjab & Haryana High Court in CWP No.26178 of 2016 titled as National Insurance Co.Ltd. Vs. Sandeep & others reported in 2017 (1) RCR (Civil) Page 621 wherein it has been  held that “Insurance companies give lucrative offers to attract customers-However, the moment any insured puts even the most genuine claim, seldom said claim would be accepted by any insurance company.”

7.                 On the other side, learned counsel for OPs has argued that the complainant has not submitted all relevant document qua the claim of complainant despite written reminders to him. As such, there was no deficiency in service on their part and claim was rightly repudiated.

8.                 It is not in dispute that on the relevant period of time complainant was under the insurance cover.  Complainant to prove that he was under treatment and incurred a sum of Rs.13,020/- on his treatment has placed on record bills/documents Annexure C-1 to Annexure C-4 and Annexure C-11, which in our view, are sufficient to process with the claim of  complainant for such petty amount but  despite that the said amount was not released by the OPs rather repudiated the claim of complainant. Perusal of record reveals that the OP has repudiated the claim of complainant in a casual manner without mentioning any cogent and convincing reason thereof which shows that the OPs insurance company has adopted a trend not to release claim of the poor persons rather compel them to knock the doors of the Consumer Commission. It is worthwhile to mention here that the OPs are not settling even genuine claims of consumers/complainants which is illegal and amounts to indulgence into unfair trade practice/malpractice. We have carefully gone through the case law relied upon by complainant side, which is very much relevant to the facts and circumstances of the present case and thus is helpful in deciding the present case.  

9.                 In view of the above discussion and going through the situation as well as facts and circumstances of the present case, it is clear that OPs have wrongly repudiated the claim of complainant just to cheat and harass the complainant which amounts to deficiency in service and mal-trade practice on their part resulting into monetary loss as well as mental and physical harassment. Hence, the complaint is allowed and the OPs, jointly and severally, are directed to comply with the following directions within 40 days from the date of order:-

(i)       To pay a sum of Rs.13,020/- (Rs. Thirteen thousand & twenty) to the complainant so incurred by him on treatment alongwith simple interest @ 9% per annum from the date of filing of complaint till actual realization.

(ii)      To pay Rs.10,000/- (Rs. Ten thousand) as compensation  on account of mental agony and physical harassment. 

3. To pay Rs.5500/- (Rs. Five thousand five hundred) as cost of litigation including Advocate’s fee.

                    In case of default, the OPs shall liable to pay simple interest @ 12% per annum on the aforesaid amount for the period of default. Certified copies of the order be sent to parties free of costs. File be consigned to the record room, after due compliance.

Announced.

Dated:20.11.2023.