Haryana

Bhiwani

CC/2/2021

Rajesh kumar - Complainant(s)

Versus

M/S Raksha TPA - Opp.Party(s)

Nitin Aggarwal

03 Apr 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSASL COMMISSION, BHIWANI.

                                                                Complaint Case No. : 02 of 2021

                                                                Date of Institution    : 07.01.2021

                                                                Date of decision:      : 03.04.2024

 

Rajesh Kumar son of Sh. Jagdish Parshad, R/o House No.83, New Anaj Mandi, Bhiwani, Tehsil and District, Bhiwani (Haryana)-127021.

                                                            ...Complainant. 

 

                                                    Versus.

1. M/s Raksha TPA Private Limited, having its office at SCO 39, 1^st Floor, Madhya Marg, above Barbeque Nation, Chandigarh-160019.

 

2. United India Insurance Company Ltd., having its Branch office at 323/18 1^st Floor, Ambedkar Chowk, Near Adarsh Cinema, Hansi, Hisar ( Haryana)-125033 through its Branch Manager.

 

....Opposite parties.

 

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

Before: -       Mrs. Saroj Bala Bohra, Presiding Member.

                    Ms. Shashi Kiran Panwar, Member.

Present:        Sh. Deepanshu Tuteja, Advocate for complainant.

Sh. Hemant Sharma, Advocate for OP No.2.

OP No.1 exparte.  

  

                                                  ORDER

 

SAROJ BALA BOHRA, PRESIDING MEMBER:

1.                 Brief facts of this case are that complainant taken a Mediclaim Insurance policy from OP No.2 for himself and his family members and the policy, as per complainant, was renewed time and again.  The policy was further renewed from 26.10.2018 to 25.10.2019 after paying premium of Rs.24,638/- from OP No.2 wherein complainant, his wife Usha Devi, daughter-Payal Goyal and son–Rahul Goyal were insured.  It is stated that on 01.09.2019, son of complainant Rahul Goayl fell ill and got admitted in Anchal Maternity and Nursing Home, Bhiwani for a period from 01.09.2019 to 06.09.2019 and a sum of Rs.28,720/- were incurred on his treatment.  Complainant submitted claim with OP No.2 annexing all medical bill and other relevant documents. The OP No.1 processed the claim and vide letter dated 23.10.2019 asked for some documents, as per complainant, complete formalities was done by him. However, the claim was not paid without any reason or rhyme.  So, legal notice datd 01.06.2020 was got served upon the OPs but of no avail. Hence, the present complaint has been preferred by complainant alleging deficiency in service resulting into monetary loss as well as mental and physical harassment.  In the end, complainant sought directions against the Ops to pay a sum of Rs.28,720/- alongwith interest @ 18% per annum from the date of admission till payment. Further to pay Rs.50,000/- on account of harassment and Rs.20000/- towards litigation expenses. Any other relief to which this Commission deems fit has also been sought.

2.                 Notices were sent to the OPs. OP No.1 did not appear despite registered notice. As such, vide order dated 18.03.2021, it was proceeded against as exparte.

3.                 OP No.2 appeared through counsel and tendered reply raising preliminary objections qua maintainability of complaint, locus standi, cause of action, jurisdiction and suppression of material facts by complainant.  On merits, it is submitted that the doctor who treated the son of complainant was a BAMS doctor and thus was/is not competent for treatment as per terms and conditions of insurance policy taken by complainant whereas, the patient can be treated only by a qualified physician. In this case BAMS doctor and Lab Pathologist are not authorized to prescribe the allopathic medicines.  As per clause 5.7, the insurance company shall not be liable to make any payment under this policy in respect of any claim if such claim be in any manner fraudulent or supported by any fraudulent means or device whether by insured person or by any other person acting on his behalf. Hence, the complainant was not entitled to any claim and it was rightly repudiated. In the end, denied for any deficiency in service and prayed for dismissal of complaint with costs.

4.                 In evidence of complainant, his affidavit Ex. CW1/A alongwith documents Ex. C-1 to Ex. C-6 were tendered and closed the evidence.

5.                 On the other side, in evidence of OP No.2, documents Ex. R-1 to Ex. R-7 were tendered and closed the evidence.

6.                 We have heard learned counsels for the parties and perused the record carefully.

7.                 The case of complainant is that during the period of insurance policy, his son fell ill and remained admitted in the concerned hospital and spent a sum of Rs.28,720/- but the OP insurance company did not reimburse the amount rather repudiated the claim of complainant vide letter dated 26.11.2019 (Ex. R-2). Ld. Counsel for complainant has argued that due to such act & conduct of OP, complainant has to suffer monetary loss as well as mental and physical harassment. 8.                   On the other side, learned counsel for OP No.2 has argued that the treating doctor of the concerned hospital was not competent for providing treatment being a BAMS doctor, as per terms and conditions of insurance policy taken by complainant.  Further, as per clause 5.7, the insurance company shall not be liable to make any payment if the claim is fraudulent or adopted any such like means.  Thus the complainant was not entitled to any claim and it was rightly repudiated within policy parameters.

9.                 It is not in dispute that on the relevant period of time complainant’s son was under the insurance cover. Complainant to prove that his case has placed on record medical treatment bills Ex. C-2  & Ex. C-3 whereby it is evident that son of complainant was admitted in the said hospital from 01.09.2019 to 06.09.2019 and complainant incurred a sum of Rs.28,720/-  on the treatment. Perusal of insurance policy and its terms and conditions (Ex. R-3 & Ex. R-7) nowhere reveal that BAMS doctor was not competent to do the treatments referred in the medical record annexed with the file as (Ex. R-5 & Ex. R-6).

10.               After hearing learned counsels for the parties and going through the record, we are of the view that OP No.2 insurance company has 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 OP No.2 is directed to comply with the following directions within 40 days from the date of order:-

(i)       To pay a sum of Rs.28,720/- (Rs. Twenty eight thousand seven hundred twenty) to the complainant so incurred by him on the treatment of his son 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 litigation expenses.

                    In case of non-compliance, all the awarded amounts shall further attract simple interest @ 12% per annum for the period of default. 

                    Further, the complainant shall be entitled to the execution petition under section 71 of Consumer Protection Act, 2019 and in that eventuality, the opposite party may also be liable for prosecution under Section 72 of the said Act which envisages punishment of imprisonment, which may extend to three years or fine upto rupees one lac or with both.  Copies of this order be sent to the parties concerned, free of costs.  File be consigned to the record room, after due compliance. 

Announced.

Dated: 03.04.2024