BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, KAITHAL.
Complaint Case No.181 of 2018.
Date of institution:29.06.2018.
Date of decision: 14.5.2019.
Jora singh age 37 years, S/o Sh. Ramphal, R/o VPO Sampan Kheri, Tehsil and Distt. Kaithal.
…Complainant.
Versus
- Max Bupa Health Insurance Company Limited, B1/1-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi-110044 through its Director/Manager.
- Max Bupa Health Insurance Company Limited, Branch Office, Dhand Road, Pehowa Chowk, Ist Floor, 28/10, Above Ganpati Graphics and Computer, Kurukshetra Road, Kaithal.
- Bajaj Finance Limited, 4th floor Viman Nagar, Finserv Off Pune-Ahmed Nagar Road, Pune-411014, Maharashtra through its Director.
- Bajaj Finance Limited, Ist floor above global sanitary, Opp. R.K.S.D. College, Ambala Road, Kaithal.
….Respondents.
Before: Sh. D.N. Arora, President.
Sh. Rajbir Singh, Member.
Smt. Suman Rana, Member.
Present: Sh. Sethpal, Advocate, for the complainant.
Sh. Hardeep Ranu, Advocate for the OPs.No.1 & 2.
Sh. Vikram Tiwari, Adv. for the Ops No.3 & 4.
ORDER
D.N.ARORA, PRESIDENT
The complainant has filed the present complaint under Section 12 of Consumer Protection Act, 1986, with the averments that he took cash loan of Rs.66,000/- on 16.01.2017 from the Ops No.3 & 4 and on the advice of Op No.4, the complainant purchased a policy No.00210900201600 dt. 16.01.2017 from the Ops No.1 & 2. It is alleged that during the insured period, the complainant was suffering from kidney stone and under the treatment at Jaipur Hospital, Kaithal and he spent Rs.2,00,000/- on his treatment. It is further alleged that the complainant lodged the claim with the Ops and submitted all the necessary documents, but the Ops did not settle the claim of complainant. So, it is a clear cut case of deficiency in service on the part of Ops and prayed for acceptance of complaint. Hence, this complaint.
2. Upon notice, the OPs appeared before this Forum and contested the complaint by filing their replies separately. OPs No.1 & 2 filed the joint reply raising preliminary objections that the complainant submitted a claim form for reimbursement of medical expenses incurred by him of only Rs.14,525/- and now he is claiming the amount of Rs.2,00,000/- and the claim of complainant was repudiated by the Op on the ground “In absence of past treatment records for the kidney stone removal”. The complainant deliberately did not provide the past treatment records to the answering Op Company. It is submitted that during the investigation, the complainant himself agreed that he underwent the treatment of kidney stone 4 years back. There is no deficiency in service on the part of Ops. On merits, the objections raised in the preliminary objections are reiterated and so, prayed for dismissal of complaint.
3. Ops No.3 & 4 filed the joint reply raising preliminary with regard to maintainability; jurisdiction; that the complainant had availed a personal loan from the Ops No.3 & 4 vide loan account No.593PST33463770 for an amount of Rs.66,000/-. The complainant had also availed insurance from the Ops No.1 & 2 under policy No. 00210900201600 dt. 16.01.2017. The complainant had undergone a surgery towards the kidney stone and after the surgery when the complainant approached the Ops No.1 & 2 for the benefit, the same was rejected.
4. The complainant tendered into evidence affidavit, Ex.CW1/A and documents Ex.C1 to Ex.C5, Mark-CA to Mark-CE and thereafter, closed the evidence.
5. On the other hand, the Ops No.1 & 2 tendered into evidence affidavit, Ex.RW1/A and documents Mark-OP1/1 to Mark-OP1/6 and thereafter, closed the evidence. The Ops No.3 & 4 tendered into evidence affidavit Ex.RW1/A and documents Ex.R1 & Ex.R2 and thereafter, closed the evidence.
6. We have heard the learned counsel for both the parties and perused the record carefully.
7. Undisputedly, the complainant took a loan of Rs.66,000/- from OPs No.3 & 4. The complainant also purchased a health insurance policy bearing No.00210900201600 dt. 16.01.2017 from the OPs No.1 & 2 valid from 16.1.2017 to 15.1.2018 (Ex.C1). The grievance of the complainant is that during the insured period, he was suffering from kidney stone and under the treatment at Jaipur Hospital, Kaithal and spent Rs.2,00,000/- on his treatment. The complainant lodged the claim with the OPs and submitted all the necessary documents, but the OPs did not settle his claim.
On the other hand, it is contended by the OPs No.1 & 2 that the claim of complainant was repudiated by the OPs on the ground “In absence of past treatment records for the kidney stone removal”. The complainant deliberately did not provide the past treatment records to the OPs Company.
8. We have considered the rival contentions of both the parties. On perusal of case file, it is clear that the OPs No.1 & 2 failed to produce the proposal form duly filled in by the complainant for taking the policy in question, on the case file and without said proposal form, this Forum is unable to come to the conclusion that whether the complainant concealed any material facts regarding his past disease from the OPs or not before taking the policy in question. Since the OPs No.1 & 2 repudiated the claim of the complainant, so the onus to prove the same, was upon the OPs No.1 & 2. But in the present case, the OPs No.1 & 2 failed to stand upon his own legs. In these facts and circumstances of the case, we are of the considered view that the OPs No.1 & 2 have committed mistake in repudiating the claim of the complainant. So, we find deficiency in service on the part of the OPs No.1 & 2. The complainant has alleged in para No.2 of his complaint that he spent Rs.2,00,000/- on his treatment but he has failed to produce any document or bills in this regard. As per Policy Document Ex.C1, the claim for Kidney Stones including DJ stent removal is fixed as Rs.15,000/-. The complainant produced his treatment details as Mark CB and as per that document, the complainant remained admitted in Jaipur Hospital, Kaithal from 18.9.2017 to 19.9.2017 and spent Rs.14,525/- on his treatment. So, the complainant is entitled for claim of Rs.14,525/-.
9. Thus, as a sequel of above discussion, we allow the complaint against the Ops No.1 & 2 and direct the OPs No.1 & 2 to pay Rs.14,525/- alongwith interest @ 9% p.a. from the date of filing of present complaint till its realization to the complainant. The Ops No.1 & 2 are also directed to pay Rs.2200/- to the complainant as lump sum compensation on account of harassment, mental agony including the litigation charges. Let the order be complied with within 30 days from the date of preparation of copy of this order. Both the OPs No.1 & 2 are jointly and severally liable. A copy of this order be sent to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
Dt.:14.5.2019.
(D.N. Arora)
President.
(Suman Rana), (Rajbir Singh)
Member Member.
