Delhi

New Delhi

CC/274/2022

Reena - Complainant(s)

Versus

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

16 May 2023

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-VI

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

I.P.ESTATE, NEW DELHI-110002.

Case No.274 /2022       

IN THE MATTER OF:

 

 

Mrs Reena

RZ-187, Nand Vihar,

Kakrola, New Delhi-110078                                             ....Complainant

 

                                      VERSUS

 

      Bajaj Allianz General Insurance Company Limited.

      12^th Floor, Dr. Gopaldass 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:-31.10.2022                                                                                                                                                                            Date of Order   : -    16.05.2023

ORDER

 

POONAM CHAUDHRY, PRESIDENT

 

 

1. The present complaint has been filed under Section 35 read with 36 of Consumer Protection Act, 2019 (in short CP Act) read with Rule 7 of the Consumer Protection (Consumer Commission Procedure) Regulations, 202, against Opposite Party ( in short OP) alleging deficiency of services.
2. Briefly stated the facts of the case are that the complainant had taken an online health insurance policy bearing no. 0G-22-1101-8441-00001837 on 31.12.2021 from opposite party. It is further stated that said policy was valid from 31.12.2021 to 30.12.2022 for the sum insured of Rs.3,00,000/- (Rupees Three Lakh).
3. The complainant’s daughter Priyanka got admitted in the Mahavir Multispeciality hospital for treatment on 25.06.2022 and remained hospitalized till 29.06.2022. The said hospital generated the final bills of Rs.44,297/- (Rupees Forty Four Thousand Two Hundred Ninety Seven) which were paid by complainant.
4. There after complainant claimed the aforesaid bill amount from the opposite party, but OP rejected the Claim No. 0C-23-1002-8441-00005410 vide letter dated 10.10.2022 with the following reason;

Verification of claim documents reveal aforesaid claimed was hospitalized for investigation and treatment of Enteric Fever and is claiming for expenses insured of INR 44,297/- (Rupees Forty Four Thousand Two Hundred Ninety Seven). As per received documents we have noticed discrepancies and lapse in your hospitalization, which are as follow:-

1. Patient presented with complaints and got admitted to hospital but first consultation details not available. Also no post discharge follow up treatment taken.
2. Patient allegedly suffering from Fever yet patient was not evaluated for notifiable disease as per government standard protocols.
3. No Lab Technician and Pathologist were available at the hospital during verification.
4. Hospital has no Registration Certificates.
5. Discrepancy noted in investigation advised by doctor and the lab entry register.

Discrepancy noted in medicine advised, prescribed and medicines issued. Hence, we regret to inform that your claim stands repudiated in view of misrepresentation of facts. Condition Precedent to Admission of Liability: The terms and conditions of the policy must be fulfilled by the insured person for the company to make any payment for claim (s) arising under the policy.

5. It is alleged that the complainant then sent a letter by speed post with all required documents vide letter dated 15.10.2022 to the OP/insurance company but no response was received from OP. The complainant having been left with no option has approached this Court. Hence, the present complaint.
6. It is also alleged the present case is being filed within the period of limitation, the cause of action arose to file case arose when the claim of the complainant rejected by opposite party on 10.10.2022. It is also alleged that the residence of the complainant is situated at New Delhi. Hence, this Commission has jurisdiction to entertain the present complaint.
7. It is prayed that OP be directed to pay a sum of Rs.44,297/- (Rupees Forty Four Thousand Two Hundred Ninety Seven)  to complainant with pendent elite and future interest @ 18% p.a. with effect from the repudiation of claim 10.10.2022 till realization. It is also prayed that OP be directed to verify and produce the medical treatment record and bills of complainant’s treatment from 25.06.2022 to 29.06.2022.  OP be also directed to pay cost of litigation.
8. Vide order dated 10.04.2023, the defence of OP was stuck off, the same is as under:

AR of complainant states that written statement has been filed beyond the statutory period.

Proof of service filed. OP was served on 15.11.2022 whereas written statement was filed 05.01.2023..

Section 38 Sub-Section 3 (a) of the Consumer Protection Act which relates to the period of limitation to file reply/written statement is 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.

In this regard the 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”.

Thus as the written statement has not been filed within the statutory period i.e. 30 days and the extended period of 15 days, the written statement cannot be taken on record.

9. Thereafter an application filed by OP for review of the order dated 10.04.2023 was dismissed vide order dated 16.05.2023., the same is as under:

“An application filed on behalf of OP for review of order dated 10.04.2023 whereby defence of OP was stuck off. It is alleged that OP received the copy of complaint on 21.11.2022.and not on 15.11.2022 as recorded in the order dated 10.04.2023. It is stated that the period of 45 days as provided in Section 38(3)(a) expires on 06.01.2023.

Application has been opposed.

Heard.

We have perused the record as per affidavit of service filed by complainant with postal receipts, OP was served on 19.11.2022 but written statement was filed on 05.01.2023. As written statement has been filed beyond the statutory period as prescribed in the Section 38(3)(a) of the Consumer Protection Act, the defence of OP was stuck off vide order dated 10.04.2023. Thus we do not find any error apparent on the face of record to review the order dated 10.04.2023.

Section 40 of Consumer Protection Act which relates to review by District Commission in certain cases provides as under:

“The District Commission shall have the power to review if there is an error apparent on the face of the record.”

We are of the view that there is no error apparent on the face of record to review the order dated 10.04.2023.Application stands dismissed.”

 

10. Complainant filed her evidence by affidavit reiterating there the averments made in the complaint. Complainant relied upon the insurance policy, the copies of bills, medical treatment record of her daughter, Registration certificate of Mahavir Multispeciality Hospital.
11. We have heard the AR of complainant and counsel for OP and perused the record.
12. 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.44,297/- (Rupees Forty Four Thousand Two Hundred Ninety Seven) 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 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)