Delhi

New Delhi

CC/265/2022

MRS. CHANDA DEVI - Complainant(s)

Versus

M/S. BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LTD. - Opp.Party(s)

29 May 2023

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-VI

(NEW DELHI), ‘M’ BLOCK, 1STFLOOR, VIKAS BHAWAN,

I.P.ESTATE, NEW DELHI-110002.

Case No.265/2022

IN THE MATTER OF:

 

Mrs. Chanda Devi

C41, 3^rd Floor, Bharat Vihar,

Kakrola, New Delhi-110078                                                  ....Complainant

 

 

VERSUS

 

Bajaj Allianz General Insurance Company Limited

12^th Floor, Dr. Gopal Dass Bhawan,

28, Barakhamba Road,

Connaught Place, New Delhi-110001                                 ....Opposite Party

 

Quorum:

 

Ms. Poonam Chaudhry, President

Sh. Bariq Ahmad, Member

Sh. Shekhar Chandra, Member

 

                                                                                                                    Date of Institution:- 19.10.2022                                                                                                                                                                        Date of Order   : -       29.05.2023

 

ORDER

 

POONAM CHAUDHRY, PRESIDENT

 

1. The present complaint has been filed under Section 12 and 35 of the Consumer Protection Act, 1986 (in short CP Act) against Opposite Party (in short OP) alleging deficiency of services.
2. Briefly stated the facts of the case are that the complainant had taken a on line health insurance policy bearing no. OG-22-1101-8441-00001964 on  20.01.2022 from opposite party. It is further alleged that said policy was valid from 20.01.2022 to 19.01.2023. for the sum insured of Rs.5,00,000/- (Rupees Five Lakh).
3. The complainant got admitted in Mahavir Multispecialty Hospital for her treatment on 27.03.2022 and remained hospitalized till 31.03.2022. The said hospital generated the final bill of Rs.44,560/- (Rupees Forty Four Thousand Five Hundred Sixty) which was paid by complainant.
4. The complainant claimed the aforesaid bill from the opposite party, but the claim of complainant No. OC-23-1002-8441-00000049 was rejected by the opposite party on 12.09.2022 with reason mentioned as under

Verification of claim documents reveal aforesaid clamant was hospitalized for investigation and treatment of urinary tract infection with Macrocytic Anemia and is claiming for expenses incurred of INR 44,560/- (Rupees Forty Four Thousand Five Hundred Sixty). As per received documents we have noticed certain discrepancies and lapses in your hospitalization, which are as follows.

1. As per the insured brother no tablets were given at the time of hospitalization whereas as per ICP it was given.
2. Hospital provided the purchase invoice but was not verified by them.
3. As per provided hospital registration certificate, dated 31.05.2022, registration is renewed and valid upto 31.03.2025. Although during the period of hospitalization i.e. 27.03.2022 to 31.03.2022, hospital was not registered.
4. Hospital provided the purchase invoice but was not verified by them.
5. Pathologist Dr. K.D. Gandhi was not reachable. Hence, we regret to inform that your claim stands repudiation in view of misrepresentation of facts with non-cooperation and as hospital criteria not fulfilled.

 

5. It is further alleged that the after complainant sent a letter by speed post with all required documents to OP on 21.09.2022 but no response was received.
6. Thus the complainant having been left with no option approached this Court. Hence, the present complaint. It is further alleged that the present case is being filed within the period of limitation. The cause of action to file present case arose when the claim of the complainant was rejected by opposite party vide letter dated 12.09.2022. It is further alleged that the residence of the complainant is situated at ‘Kakrola’ New Delhi, hence, this Court has jurisdiction to entertain the present complaint.
7. It is prayed that OP be directed to pay a sum of Rs.44,560/- (Rupees Forty Four Thousand Five Hundred Sixty) to the complainant with pendentelite and future interest @ 18 % p.a. from the date of repudiation of claim on 12.09.2022 till its realization. OP be also directed to verify and produce the medical treatment record and bills of complainant’s treatment from 27.03.2022 to 31.03.2022. Cost of litigation be also awarded.
8. Notice of the complaint was issued to OP, OP was duly served on 29.11.2022. However OP did not filed written statement within statutory period as such the defence of OP was stuck off vide order dated 13.02.2023.  An application filed by OP for review of the order dated 13.02.2023 was dismissed vide order dated 06.03.2023.
9. Complainant filed her evidence by affidavit reiterating therein the averments made in the complaint. Complainant relied upon the insurance policy, the bills and treatment record of Mahavir Multispecialty Hospital. The registration certificate of Mahavir Multispecialty hospital valid till 31^st March, 2025. It is to be noted that the policy in question was valid with effect from 20.01.2022 to 19.01.2023. Complainant was hospitalized during the continuance of the policy. Bills and treatment record of the hospital have been filed.
10. We have heard the AR of complainant and counsel for OP and perused the record.
11. In view of the unrebutted testimony of complainant and the documents filed and replied upon, we are of the view that complainant has succeeded in proving that OP was  guilty of deficiency of services in repudiating the claim of complainant. We accordingly hold OP/Bajaj Allianz General Insurance Company guilty of deficiency of services and direct OP to pay Rs.44,560/- (Rupees Forty Four Thousand Five Hundred Sixty) to the complainant with interest @ 9% per annum from date of filing of claim, within four weeks of date of receipt of order, failing which OP will be liable to pay interest @ 12% per annum till realization. We also direct OP to pay compensation of Rs.50,000/ (Rupees Fifty Thousand only) for mental agony and harassment caused to complainant and Rs.10,000/- (Rupees Ten Thousand only) as cost of litigation to the complainant.

A copy of this order be sent/provided to all the parties free of cost. The order be uploaded on the website of this Commission.

File be consigned to record room along with a copy of the order.

 

 

Poonam Chaudhry

(President)

 Bariq Ahmad                                                                                                                  Shekhar Chandra

    (Member)                                                                                                                          (Member)