BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, JALANDHAR.

Complaint No.373 of 11.09.2018

Date of Decision:23.02.2021

Meena Kalia W/o of Sh. Ashok Kumar Kalia son of Sh.Charan Dass Kalia, resident of 19, Guru Nanak Nagar, Model Town, Jalandhar.

..........Complainant

Versus

National Insurance Company Limited, DAB-II, Near BMC Chowk, 20, G.T. Road, Jalandhar City, through its Branch Manager.

….….. Opposite Party

Complaint Under the Consumer Protection Act.

Before:

Sh. Kuljit Singh, President

Smt.Jyotsna, Member

COUNSEL FOR THE PARTIES:-

For complainant : Sh.K.L. Dua, Advocate

For OP : Sh.A.K. Arora, Advocate

Order

PER Kuljit Singh, President

1. The instant complaint has been filed by the complainant, wherein she alleged that she purchased joint health insurance policy No.404300/48/17/850000/180 CCN No.3816416 for Rs.2,00,000/-. Policy was valid from 18.09.2017 to 17.09.2018. The policy covered the amount spent on the medical treatment of complainant and her husband Ashok Kumar Kalia during the validity of said policy. Complainant was admitted in Jawanti Hospital and Nursing Home Pvt Ltd, Jalandhar City; as she was not well and remained admitted in the said hospital for treatment from 19.02.2018 to 20.02.2018. Complainant spent Rs.5391/- on her treatment in said hospital as an indoor patient. After discharge from said hospital, the complainant submitted bill for Rs.5391/- for reimbursement of said amount. Her bill has not been paid. OP has contravened the terms and conditions of said policy by not making payment. Some objections were raised by OP and he submitted complete claim papers after removing objection on 10.05.2018. Complainant has written many letters to OP through email but of no effect. Lastly, prayer has been made that OP be directed to make payment of Rs.5391/- spent on her treatment alongwith interest @12% per annum from 22.02.2018 till realization. Further, she claimed Rs.10,000/- as compensation and Rs.13,000/- on account of cost of legal notice and litigation expenses.

2. Notice of the complaint was given to the OP and accordingly, OP appeared through its counsel and filed written reply, whereby contested the complaint by taking preliminary objections that there is no deficiency in service, unfair trade practice; complainant was issued Baroda Health Policy by Ops for the period of 18.09.2017 to 17.09.2018. The said policy was subject to terms and conditions of policy. The complainant lodged a claim with OP regarding her treatment for her ailment i.e. Coad with age from Lajwanti Hospital for the period 19.02.2018 to 20.02.2018 for Rs.5391/- as an indoor patient. All documents in respect of said claim were sent by OP to Paramount Health Services and Insurance TPA Pvt Ltd. The complainant was called upon vide letters dated 15.03.2018, 31.03.2018, 16.04.2018, 05.05.2018 and 16.05.2018 by said TPA to provide (a) presenting complaints with duration from the treating doctor; (b) since when the patient is known case of COAD from the treating doctor (c) all previous consultation papers. Despite said letter written to her husband, complainant has not complied with said requirements of Claim Settling Agency of OP and as such, her claim was closed by said agency and letter dated 23.05.2018 to this effect was written to her. On merits, policy of complainant and treatment taken by complainant is admitted and spent of amount by complainant is also admitted. There is no question of making payment to complainant as the claim has already been closed for non-completion of formalities as referred and letter dated 23.05.2018 written to complainant. All other averments of complaint denied and prayed for dismissal of present complaint with costs.

3. In order to prove the case of the complainant, the counsel for the complainant has filed affidavit of complainant Ex.CW1/A alongwith some documents Ex.C-1 to Ex.C-24 and closed the evidence.

4. In order to rebut the evidence of the complainant, the counsel for OP filed affidavit of Kuldip Raj Divisional Manager and some documents Ex.O1 to Ex.O-7.

5. We have heard the argument from learned counsel for the respective parties and also gone through the case file very carefully.

6. It is an admitted fact that the complainant has purchased joint Health Insurance Policy No.404300/48/17/850000/180 CCN No.3816416 for Rs.2,00,000/- from OP for the period 18.09.2017 to 17.09.2018 which also covered her husband – Ashok Kumar Kalia and the said policy is Ex. C-2. It is also an admitted fact that during the period of insurance 19.02.2018 to 20.02.2018, the complainant fell ill and was hospitalized in Lajwanti Hospital, Jalandhar City and she remained admitted there for the period 19.02.2018 to 20.02.2018 and had undergone for her treatment as an indoor patient and had paid a sum of Rs.5,391/- and its bill has been placed on the record. The discharge summary of said Hospital has also been placed on the record, which shows that the complainant remained admitted with said hospital at Jalandhar City from 19.02.2018 to 20.02.2018 and had undergone for treatment. It was argued by the counsel for the complainant that although it was the duty of the OP to reimburse the amount spent by complainant on her treatment but when the bill was submitted to the OP, they declined the same on flimsy grounds that the complainant has not supplied the requisite documents as Ex.O-7 and due to non-submission of said documents, the OP treated her claim as No claim. But counsel for the complainant has referred to the discharge card which the complainant was admitted in hospital from 19.02.2018 to 20.02.2018. Therefore, the basis on which the claim has been repudiated is not correct. Therefore, it was argued by the counsel for the complainant that the claim of Rs.5391/- spent by the complainant be allowed.

7. OP has repudiated the claim on the basis that complainant has failed to submit requisite documents as Ex.O-7. Therefore, in the absence of any specific evidence on the record, mere reference in the record mentioned by OP that admission in hospital is not required is not sufficient to say so. Moreover, the OP has failed to produce on regard, certificate or affidavit of concerned doctor regarding admission of complainant is required or not required for his treatment. The reasons for rejection of claim of the complainant are without any base and are contrary to the documentary evidence produced by the complainant.

8. In view of the above discussion, the present complaint is partly allowed and the OP is directed to pay Rs.5391/- i.e. bill amount of treatment of complainant alongwith interest @ 5% per annum from the date of repudiation of claim till realization.  The complainant has been harassed by the OP as her claim has not been settled, hence the complainant is held entitled for compensation and litigation expenses of Rs.2000/-. The OP has no right to keep and misappropriate the public money. It must go back to the public. We, therefore, order that the OP will deposit a sum of Rs.1000/-, the estimate rough amount, with the legal aid account of this Commission. Opposite Party is directed to comply with the order within 45 days from the receipt of copy of the order

9. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room after its due compliance.

ANNOUNCED IN THE OPEN COMMISSION:

23^rd Day of February 2021

(Kuljit Singh)

President

(Jyotsna)

Member