Before the District Consumer Disputes Redressed Commission, Rohtak.

                                                          Complaint No. : 488.

                                                          Instituted on     : 22.08.2017.

                                                          Decided on       : 26.10.2021.

Surender Bansal c/o M/s Dinesh Textiles, Lal Cloth Market, Railway Road, Rohtak.

                                                                             ………..Complainant.

                                      Vs.

Oriental Insurance Company Ltd., Post Box No.7037-25/27, Asaf Ali Road, New Delhi.  

……….Opposite party.

COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.

BEFORE:  SH.NAGENDER SINGH KADIAN, PRESIDENT.

                   DR. TRIPTI PANNU, MEMBER.

Present:       Sh.N.P.Sharma, Advocate for the complainant.

                   Sh.R.K.Bhardwaj, Advocate for opposite party.

                                      ORDER

NAGENDER SINGH KADIAN, PRESIDENT:

1.                Brief facts of the case are that complainant purchased a family medi-claim policy No.261200/48/2015/961 on dated 13.08.2014 commenced from 17.08.2014 in continuous of the previous policy No.261200/48/2014/894 by covering the family members of the complainant(including the complainant) by covering them upto 16.08.2015. On 14.11.2014 the son of the complainant namely Sidharth suffered stomach pain and got admitted in Shivam Lever Gastro Superspeciality Hospital HUDA Complex, Rohtak on 14.11.2014 to 18.11.2014 and later on 18.11.20914 shifted to Maharaja Aggarsain  Hospital, Delhi where he was also admitted from 18.11.2014 to 23.11.2014 and the complainant had to spent an amount of more than Rs.30000/- on the treatment. The expenses of Maharaja Aggarsain Hospital was to indemnify by the respondent, but the respondent did not pay the amount of medical expenses/treatment bills spent by the complainant at Rohtak even after submitting the bills in detail and expenses occurred  by the complainant with all requisite documents as required by the respondent for getting medical claim under the policy. The complainant requested the opposite party many times in oral as well as in written and is still in touch with the respondent for the same but the respondent avoided to the genuine request of the complainant. Hence this complaint and it is prayed that opposite party may kindly be directed to pay Rs.30000/- alongwith other expenses of Rs.50000/- and compensation on account of mental and physical harassment of Rs.25000 alongwith interest and legal fees to the complainant.

2.                After registration of complaint, notice was issued to the opposite party. Opposite party in preliminary objections of their reply has submitted that the petitioner was discharged on 18.11.2014 from the hospital and he submitted his claim form on 17.04.2015. Thus there is a violation of terms and conditions of the policy as per condition no.5.6 o the policy. As per condition no.5.6 of the policy, final claim alongwith original hospital bills and documents should be submitted to the company/TPA within 7 days of discharge from the hospital or nursing home. On merits it is submitted that it is wrong that Sidharth suffered stomach pain on 14/11/2014 and discharged on 18/11/2014. It is also wrong that the complainant was shifted to Aggarsain  hospital where he discharged on dated 23/11/2014. The whole para is wrong and denied. It is also wrong that the complainant spent Rs.30000/- on treatment at Rohtak which the answering respondent did not pay. The real facts are that the complainant did not file claim form in time and there is violation of terms and condition no.5.6 of the policy. Therefore claim was not settled and is not payable. All the other contents of the complaint were stated to be wrong and denied and opposite party prayed for dismissal of complaint with costs.

3.                Ld. counsel for the complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C17 and failed to conclude his evidence. Hence the evidence of complainant was closed by the order dated 27.02.2019 of this Commission.. On the other hand, ld. Counsel for the opposite party has placed on record affidavit Ex.RW1/A, documents Ex.R1 to Ex.R17 and closed his evidence on 17.07.2019. Ld. counsel for the opposite party has also tendered documents Ex.R18 & Ex.R19 in additional evidence and closed his additional evidence on dated 28.09.2021.

4.                We have heard learned counsel for the parties and have gone through the documents placed on record very carefully.

5.                In the present case the claim of the complainant regarding admission of his son at Shivam Gastro Hospital, Rohtak was repudiated by the opposite party on the ground of delayed intimation. However, it was within the knowledge of respondent that the complainant shifted  his son from Shivam Gastro Super Speciality hospital  to Maharaja Aggarsain Hospital Delhi and cashless claim of Maharaja Aggarsain Hospital was paid by the opposite party.  From Ex.R18 it is proved that previous claim of complainant for the treatment of his son at Shivam Liver Gastro has not been paid on the ground of delayed intimation. As per Ex.R18  this intimation was given by the complainant on 17.04.2015 . At the time of arguments, ld. Counsel for the complainant has placed on record another  document as Annexure-JNA which has been submitted before the insurance company on 30.11.2014 and seal is affixed alongwith signature and date. Meaning thereby Ex.R18 is a second application for the reimbursement of treatment bill.  However, expenses of Maharaja Aggarsain hospital has already indemnified by the opposite party. 

6.                We have checked date and time  mentioned on application Annexure JN-A which is 30.11.2014 and there was Sunday on that day. On Saturday and Sunday all the offices of insurance companies are closed and no emergency services are provided at reception by the company for the purpose of receiving applications. Hence Annexure JNA is a false and fabricated document.

7.                But as per bill Ex. C6 it is proved that complainant had spent Rs.20714/- for the treatment of his son at Shivam Liver & Gastro Superspeciality Hospital. Hence he is entitled for this amount also. Regarding the delayed intimation, ld. Counsel for the complainant has placed reliance upon the ratio of law laid down in Civil Appeal No.15611 of 2017 of Hon’ble Supreme Court of India titled as Om Parkash Vs. Reliance Gen. Insurance and Anr., order dated 25.01.2019 of Hon’ble National Commission, New Delhi titled as National Insurance Co. Ltd. Vs. Anil Trading Co. which are fully applicable on the facts and circumstances of the case.

8.                In view of the above, complaint is allowed and we hereby direct the opposite party to pay a sum of Rs.20714/-(Rupees twenty thousand seven hundred and fourteen only) and Rs.3000/-(Rupees three thousand only) as compensation and litigation expenses to the complainant within 45 days from the date of order, failing which opposite party shall be liable to pay interest @ 9% p.a. from the date of order till its realization to the complainant.

9.                Copy of this order be supplied to both the party free of costs. File be consigned to the record room after due compliance.

Announced in open court:

26.10.2021.

                                                          ................................................

                                                          Nagender Singh Kadian, President

                                                          ...............................................

                                                          Tripti Pannu, Member.