District Consumer Disputes Redressal Commission ,Faridabad.

Consumer Complaint  No.220/2021

 Date of Institution: 13.04.2021.

Date of Order: 06.07.2022.

Mohan aged about 25 years S/o Shri Sonpal r/o VPO Sagarpur, Tehsil Ballabgarh, Near Govt. School of Sagarpur, District Faridabad. Aadhar No. 410018389972.

                                                                   …….Complainant……..

                                                Versus

1.                M/s. Royal Sundram General Insurance Co. Ltd., (formerly known as Royal Sundram Alliance Insurance Co. Ltd.) “Vishranthi Melaram Towers” No.2/319, Rajiv Gandhi Salai (MOR), Karapakkam, Chennai, TN- 600097. Through its Managing Director/Director/Principal Officer.

2.                M/s. Royal Sundram General Insurance Co. Ltd., (Formerly known as Royal Sundram Allianz Insurance co. Ltd.) Rider House, Plot NO. 136, Sector-44, Gurgaon-122001 through its Managing Director/Director/Principal Officer.

                                                                    …Opposite parties……

Complaint under section-12 of Consumer Protection Act, 1986

Now  amended  Section 34 of Consumer protection Act 2019.

BEFORE:            Amit Arora……………..President

Mukesh Sharma…………Member.

PRESENT:                    Sh.  Pawan Kumar, counsel for the complainant.

                             Sh.  Sachinder Bhatia, counsel for opposite parties. Nos.1 & 2.

ORDER:  

                             The facts in brief of the complaint are that  the complainant was the policy holder  of opposite parties bearing policy No. DOM0012369000100 valid from 25.07.2019 to 24.07.2020 for sum assured of Rs.5,00,000/-.  During the period of insurance policy on 06.07.2020 the complainant was suddenly sick and went to Sunshine Hospitalm Sector-64, Sahupura Road, Unchagaon, Ballabgarh with complaint of fever on and off since 7-8 days, high grade with chills since morning, pain abdomen on and off since 4-5 days, burning micturition, vomiting, weakness, dizziness, bodyache, nausea where the doctors of the said hospital medically examined and advised him to admit in hospital.  The doctor of the said hospital had made request to the opposite parties for pre-authorization and after their approval the doctor had admitted the complainant in the hospital.  The complainant after diagnosed had discharged on 11.07.2020  and the said hospital had charged the amount of Rs.38,801/- from the complainant.  The complainant had lodged claim with the opposite parties with the requisite documents which was duly received by the opposite parties with a request to disburse the claimed amount. The complainant requested the opposite parties many a times to release the claimed amount , but the opposite parties did not pay any heed upon the request of the complainant and refused to release the claimed amount vide reputation letter dated 25.11.2020 with some false excuses.  The complainant sent a legal notice dated 5.3.2021 to the opposite parties through his counsel but all in vain. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint.  The complainant has prayed for directions to the opposite party to:

a)                 pay the claimed amount of Rs.38,801/- alongwith interest @ 18% p.a. from the date of due till actual payment.

b)                 pay Rs.20,000/- as compensation for causing mental agony and harassment .

c)                 pay Rs.11,000/ - as litigation expenses .

2.                Opposite parties  Nos.1 & 2 put in appearance through counsel and filed written statement wherein Opposite parties refuted claim of the complainant and submitted that  the complainant admitted in Sunshine Hospital Uncha Gaon Ballabgarh for a problem of fever, pain abdomen, vomiting, weakness and ghabrahat and for this the hospital diagnoses that the complainant was having Entric fever with uti and admitted on 06.07.2020 and discharge don 11.07.2020 and hospital charged an amount of Rs.38,801/- from the complainant.  Further the complainant applied for reimbursement upon the opposite party by filing the claim form and depositing the requisite documents and after going through the complete documents by the opposite party and after scrutinizing the claim record the opposite party issued a letter dated 25.11.2020 stated that the after scrutiny the claim records submitted and verification of additional record reveals gross discrepancies and stay had been unduly prolonged.  The charges were also grossly exaggerated to derive undue benefit out of policy, hence they regretted their inability to  consider the claim on the above grounds therefore in view of the above facts and reasons the claim of the complainant closed by the opposite party as per the terms and conditions of the insurance policy. Opposite parties denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.

3.                The parties led evidence in support of their respective versions.

4.                 We have heard learned counsel for the parties and have gone through the record on the file.

5.                In this case the complaint was filed by the complainant against opposite parties – M/s. Royal Sundram General Insurance Co. Ltd.. with the prayer to : a)  pay the claimed amount of Rs.38,801/- alongwith interest @ 18% p.a. from the date of due till actual payment. b) pay Rs.20,000/- as compensation for causing mental agony and harassment . c) pay Rs.11,000/ - as litigation expenses .

                   To establish his case the complainant has led in his evidence Ex.CW1/A – affidavit of Shri Mohan, Ex. C-1 – letter dated July 25, 2019, Ex. C-2 -  insurance policy, Ex.C-3 – Discharge summary , Ex.C-4 – Bill/Receipt dated 11.7.2020, Ex.C-5 – Repudiation letter,

                   On the other hand counsel for the opposite parties strongly agitated and opposed. As per the evidence of the opposite parties, Ex.RW1/A – affidavit of Shri Prashant Pratap Singh, Deputy Manager, M/s. Royal Sundaram General Insurance Co. Ltd., Gurgaam, Ex.O/1 – Claim form,, Ex.O/2 – Discharge summary,, Ex.O/3 -  Aaizon Healthcare Services, Ex.O/4 – Repudiation letter, Ex.O/5 – Bill/Receipt dated 11.7.2020,, Ex.O/6 – Cash memo/Estimate dated 11.07.2020,, Ex.O/7 – receipt dated 6.7.2020, Ex.O/8 – bill dated 11.07.2020, Ex.O/9 – Details of Sunshine Hospital, Ex.O/10 – Indoor patient record,, Ex.O/11 – History sheet, Ex.O/12 -  progress note, Ex.O/13 – Patient label (Vital sign chart)

6.                After going through the evidence led by parties, the Commission is of the opinion  that  the complaint is allowed. Opposite parties are directed to process the claim of the complainant within 30 days  of receipt of the copy of order and pay the due amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint  till its realization.  The opposite parties are also directed to

pay Rs.2200/- as compensation on account of mental tension, agony and harassment alongwith Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties  concerned free of costs and file be consigned to record room.

Announced on:  06.07.2022                                 (Amit Arora)

                                                                                  President

                     District Consumer Disputes

           Redressal  Commission, Faridabad.

                                                (Mukesh Sharma)

                Member

          District Consumer Disputes

                                                                    Redressal Commission, Faridabad.