Delhi

New Delhi

CC/82/2020

Rajni - Complainant(s)

Versus

M/S. Bajaj Allianz General Insurance Company Ltd. - Opp.Party(s)

20 Apr 2023

ORDER

 

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-VI

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

I.P.ESTATE, NEW DELHI-110002.

Case No.CC-82/2020

IN THE MATTER OF:

Rajni

RZ-65, Nand Vihar, Kakrola,

New Delhi – 110078.                                                            ...Complainant

Versus

 

1. Bajaj Allianz General Insurance Company Ltd.,

         12^th Floor, Dr. Gopal Dass Bhawan,28

     Barakhamba Road, Connaught Place, New Delhi-110001.

2. Parth Hospital

               H.No. 25, Vikas Nagar, Ranholla Road,

           MLA Office, Uttam Nagar, New Delhi – 110059                        ....Opposite Parties

 

Quorum:

 

Ms. Poonam Chaudhry, President

Sh. Shekhar Chandra, Member

                                                  Date of Institution:07.09.2020

                                  Date of Order              : 20.04.2023

 

ORDER

 

POONAM CHAUDHRY, PRESIDENT

 

1. The present complaint has been filed under the Consumer Protection Act  (in short CP Act) against Opposite Parties (in short OP) alleging deficiency of services.
2. Briefly stated facts of the case are that the complainant had taken a Health Medical Claim Policy bearing No.OG-1101-8429-00000619 dated 24.06.2019 from OP No. 1 w.e.f. 24.06.2019 to 23.06.2020 for the sum insured of Rs.3,00,000/- (Three Lacs only).
3. It is further alleged that on 01.04.2000, the Complainant got admitted in OP No.2, hospital due to fever, vomiting, Abdomen pain and on 05.04.2020 the complainant was discharged from OP No. 2.  It is also alleged that OP No. 2 generated the medical treatment bill of Rs.37,193/- (Rupees Thirty Seven Thousand One Hundred Ninety Three only) which was paid by Complainant to OP No. 2. The complainant thereafter claimed the aforesaid bill from OP No.1 but the same was repudiated by OP No. 1 vide letter dated 27.07.2020. It is alleged that the medical documents submitted by the Complainant with OP No. 1 were issued by the OP No. 2.
4. It was also stated that the present case has been filed within the period of limitation. The complainant is a  resident of “Kakrola” New Delhi and OP No. 1 works for gain within the jurisdiction of this Commission, hence this Commission has jurisdiction to try and decide the case.
5. It is prayed that OP No.1 be directed to pay a sum of Rs.37,193/- (Rupees Thirty Seven Thousand One Hundred Ninety Three only)  to complainant and with pendent elite and future interest @ 18% p.a. from the date of repudiation 27.07.2020 till its realization. It is also prayed OP No. 2 be directed to verify and produce the medical treatment record and bills of complainant w.e.f. 01.04.2020 to 05.04.2020.  OP be also directed to pay cost of litigation.
6. Notice of the complaint was issued to OP No.1 and 2, upon which OP No.-1 entered appearance and filed reply/written statement contesting the complaint on various grounds, inter alia that complaint was not maintainable as it was filed on false and frivolous facts. It was also stated that there was no deficiency in service on part of the OP No.1. It was further stated that the admission of the complainant to the OP No. 2 hospital for fever and weakness for four days was without any basis since the pathologist, Dr. R.S. Kushwaha had written a letter to the OP No. 1 stating that the reports of the complainant were fake and  had not been verified by him. Dr. R.S. Kushwaha had further stated that he does not visit the OP No. 2/ hospital. It was further alleged that complainant and the OP No. 2 are hand in glove in trying to deceive the OP No. 1 with the intention of getting insurance money from the OP No. 1 by fabricating documents of a medical claim.
7. It was further stated that the standard medical protocols had not been followed during the alleged hospitalization.  The complainant had claimed that she was admitted for five days and yet no tests were done on the complainant for notifiable diseases which is the standard medical protocol.
8. It was further alleged that the OP No. 2 has also been refusing to provide records of the Complainant to the OP No.1.  The OP No. 2 hospitals did not cooperate with the OP No. 1 and no record of alleged treatment was shown despite requests. It was also alleged the clause D of the terms and conditions of the policy on the basis of which the claim was repudiated is as under:

“Where this Policy requires you to do or not to do something, then the complete satisfaction of that requirement by you or someone claiming on your behalf is a precondition to any obligation We have under this Policy. If you or someone claiming on your behalf fails to completely satisfy that requirement, then we may refuse to consider your claim.”

9. It was also alleged that the complaint is not maintainable as the same has been filed under the Consumer Protection Act, 1986, instead of Consumer Protection Act, 2019 which had been notified in July 2020.  The Complaint has been filed after the coming into force of the 2019 Act. It was also alleged that there is no deficiency in service on the part of this insurance company and it is the complainant who is at fault and has not come with clean hands.
10. That the complainant filed rejoinder stating therein that all investigations were done by Dr. R. S. Kushwaha and the pathology certificate has been filed.  It was also stated that in the past claims which were rejected and on similar grounds were later settled. 
11. Both parties filed their evidence by affidavit. We have heard the Ld. counsels for parties and perused the record.
12. The name of OP No. 2 i.e. Parth Hospital was deleted under order dated 23.03.2023.
13. It is stated by AR of complainant that the reply of OP cannot be taken on record as same has been filed beyond the period of limitation. It is alleged that OP was served on 06.02.2021 but reply was filed on 29.06.2021. It is to be noted that Section 38 Sub-Section 3 (a) of the Consumer Protection Act which relates to the period of limitation to file reply/written statement provides as follows:

“(a) refer a copy of such complaint to be opposite party directing him to give him version of the case within a period of thirty days or such extended period not exceeding fifteen days as may be granted by the District Commission.

14. It is also to be noted that Hon’ble Supreme Court has held in the case titled New India Assurance Company Ltd. Vs. Hilli Multipurpose Cold storage Pvt. Ltd. reported in 2020 (5 ) SCC 757 as under:

“Sub Section (2)(a) of Section 13 of the Consumer Protection Act provides for the opposite party to give his response ‘within a period of 30 days or such extended period not exceeding 15 days as may be granted by the District Forum’. The intention of the legislature seems to be very clear that the opposite party would get the time of 30 days, and in addition another 15 days at the discretion under the Act”.

15. In view of the above judgment, we are of the view that written statement of OP No.1 cannot be taken on record, the defence of OP No.1 stands stuck off.
16.  Complainant has filed copy of his discharge card, record of his treatment in OP-2/hospital, a letter of OP No.2  stating that Dr. R.S. Kushwaha  was the consultant of the OP-2 from 20.02.2019 to 31.08.2020. Appointment letter of Dr. R.S. Kushwaha as pathologist in OP No.2 The final bill issued by OP No.2, repudiation letter dated 27.07.2020.

 

17. In view of the unrebutted testimony of complainant, we hold that OP No.1 i.e. Bajaj Allianz General Insurance Company Ltd. guilty of deficiency of services and direct OP No.1 to pay Rs.37,193/- (Rupees Thirty Seven Thousand One Hundred Ninety Three only) to the complainant with interest @ 9% per annum from date of repudiation of claim, within four weeks of date of receipt of order failing which OP No.-1will be liable to pay interest @ 12% per annum till realization. We also direct OP No.1 to pay compensation of Rs.25,000/ (Rupees Twenty Five Thousand only) for mental agony and Rs.10,000/- (Rupees Ten Thousand only) as cost of litigation to the complainant.

 

A copy of this order be sent 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)

 

 

 

                                            Shekhar Chandra

(Member)