BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.
Complainant No. 329 of 2011
Date of instt.6.6.2011
Date of decision:2.02.2015
Suresh Garg son of Shri Sita Ram resident of House No.A-3, Purshotam Garden, Karnal.
Vs.
1. Reliance General Insurance Reliance Healthwise Ploicy Schedule, 570, Naigaon Cross Road, Next to Royal Industrial Estate Wadala (W)Mumbai.
2.Medi Assist India TPA Pvt.Ltd.SCO No.61, 2nd Floor, Phase-7,SAS Nagar, Mohali, Punjab
3.Vikas Narula Reliance Agent, 402, Basement, Mughal Canal Market, Karnal.
……… Opposite party
Complaint U/s 12 of the Consumer
Protection Act.
Before Sh.Subhash Goyal……. President.
Smt.Shashi Sharma……….Member.
Present Sh.Rakeshwar Jain Advocate for the complainant.
Sh.Rohit Gupta Advocate for the OP no.1.
OP No.2 and 3 ex parte.
ORDER:
The complainant has filed the present complaint against the Ops u/s 12 of the Consumer Protection Act on the allegations that the complainant obtained health care policy bearing No. 2005/702825000331 from OP no.1 and the same valid upto 1.6.2011. It has been further alleged that the complainant suffered high fever and was admitted to the Hospital of Dr.Parveen Garg, on 5.10.2010 and was discharged on 12.10.2010 and amount of Rs.62152/- was incurred on his treatment. The complainant lodged the claim with the Ops and furnished all the documents but the claim of the complainant was repudiated vide letter dated 20.12.2010 which amounts to deficient in services on the part of the Ops. Thus, the complainant has filed the present complaint against the Ops alleging deficiency in services and has prayed for payment of the claim amount alongwith compensation for the harassment caused to him alongwith litigation expenses. He has also tendered his affidavit in support of the contents of the complaint.
2. On notice the OP No.1 appeared and filed its written statement raising the preliminary objections that the complainant was estopped by his own act and conduct from filing the present complaint that the complaint was not maintainable; that the complainant has got no locus standi to file the present complaint and that the complainant has got no cause of action to file the present complaint and that this Forum has got no jurisdiction to entertain and to try the present complaint.
On merits, the OP has denied the allegations that the complainant was suffering from dengue. The OP has also denied the repudiation of the claim intentionally or with malafide intention. It was also denied that the complainant spent Rs.62132/- on his treatment. It was also contended that there was no deficiency in services on the part of the Ops and dismissal of the complaint has been sought.
3. We have heard the learned counsel for the parties and have gone through the case file very carefully.
4. Therefore, after going through the circumstances of the case, evidence on the file and the arguments advanced by the counsel for the parties, it emerges that the complainant has filed the present complaint against the Ops on the allegations that she was holder of policy of health care of the OP no.1 which was valid w.e.f. 2.6.2010 upto 1.6.2011 and during the subsistence of the said policy, the complainant was admitted to Dr.Parveen Garg Hospital, Karnal and he lodged claim with the OP but the OP repudiated the said claim vide Ex.C1. The complainant has challenged the repudiation of the claim.
5. However, as per the contention of the Ops the claim has rightly been repudiated because upon verification it was found that the bills were fake as reported by the PROBUS, the investigating agency vide report Ex.O3. However, after going through the repudiation letter, it emerges that grounds have been taken in a whimsical manner. There is nothing on the file that the complainant did not take treatment from Dr.Parveen Garg, Hospital. There is nothing on the file that the complainant did not incur the expenses while admitted in Dr.Parveen Garg, Hospital Ex.O5 The complainant has purchased medicines which were prescribed by the doctor and were submitted to the Ops for re imbursement. The photo copies of the said medical bills have been placed on the file by the OP which were part of the claim file. There is nothing on the file in order to infer that the said medicines were not prescribed by the concerned doctor and were not purchased by the complainant. Therefore, in the absence of any evidence to the contrary, it has to be held that repudiation of the claim by the Ops was not sustainable and the same tantamounts to deficiency in services on the part of the Ops.
6. Therefore, as a sequel to our above discussion, we accept the present complaint and direct the Ops to make the payment of Rs. 58757/- on account of bill Ex.C3 and purchase of the medicines, to the complainant alongwith interest @ 9% per annum from the date of filing of the present complaint i.e. 06.06.2011 till its actual realization. The complainant shall also be entitled for a sum of Rs.7000/- for the harassment caused to him and a sum of Rs.2200/- towards legal fee and litigation expenses. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.
Announced:
02.02.2015
(Subhash Goyal)
President,
District Consumer Disputes
Redressal Forum, Karnal.
(Smt.Shashi Sharma)
( Member
Present Sh.Rakeshwar Jain Advocate for the complainant.
Sh.Rohit Gupta Advocate for the OP no.1.
OP No.2 and 3 ex parte.
Arguments heard. Vide our separate order of the even date, the present complaint has been accepted. The parties concerned be communicated of the order accordingly and the file be unsigned to the record room after due compliance.
Announced:
02.02.2015
(Subhash Goyal)
President,
District Consumer Disputes
Redressal Forum, Karnal.
(Smt.Shashi Sharma)
( Member
