Punjab

Sangrur

CC/202/2018

Dr.Mukesh Dhawan - Complainant(s)

Versus

Religare Health Insurance co.Ltd. - Opp.Party(s)

Sh.Rattan Kumar Verma

08 Apr 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                                               

                                                Complaint No.    202

                                                Instituted on:      24.04.2018

                                                Decided on:       08.04.2019

 

 

Dr. Mukesh Dhawan S/o Om Parkash, Street No. 9, Krishanprua Colony, Sangrur.

                                                        …Complainant

                                Versus

 

1.     Religare Health Insurance Co. Ltd. through its Managing Director, 5^th Floor, 19, Chawla House, Nehru Palace, New Delhi 110 019.

2.     Columbia Asia Hospital, Bhupindera Road, Near 22 No.Fatak, Patiala 147 001 through its Manager.

                                                        ..Opposite parties

 

 

For the complainant            :       Shri Rattan Verma, Adv.

For Opp.party No.1            :       Shri Jatinder Verma, Adv.

For Opp.party No.2            :       Exparte.

 

 

 

Quorum:    Vinod Kumar Gulati, Presiding Member

                Manisha, Member

 

 

Order by: Vinod Kumar Gulati, Member.

 

 

1.             Dr. Mukesh Dhawan, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant is a consumer of the OPs by purchasing a health insurance policy from OP number 1 bearing number 11348978 on 14.6.2017 by paying the requisite premium of Rs.13904/- and the policy was valid for the period from 14.6.2017 to 13.6.2018.    The case of the complainant is that during the subsistence of the insurance policy, the complainant suffered abdominal problem and as such approached the OP number 2 hospital on 29.7.2017 and the OP number 2 assured that the amount spent on the treatment of the complainant would be collected from the OP number 1 as the complainant remained admitted from 29.7.2017 to 30.7.2017 for more than 12 hours and was discharged from the hospital at about 7 PM and by this way, the OP number 1 charged an amount of Rs.13,241/- from the complainant. Though the complainant requested the OP number 1 to refund the amount, but all in vain, despite serving of legal notice dated 11.8.2017.  Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the OPs be directed to pay to the complainant the amount of Rs.13,904/-  along with interest @ 18% per annum from the date of treatment till realisation and further claimed compensation and litigation expenses.

 

2.             In reply of the complaint filed by the OP number 1, preliminary objections have been taken up on the grounds that the complaint that the complaint is not maintainable, that the complainant has filed the complaint with malafide intention, that  prima facie no cause of action has arisen in favour of the complainant, that the complaint is false, frivolous and vexatious in nature. On merits, it is admitted that the complainant took a health insurance policy in question for Rs.5,00,000/-. It is further stated that the alleged claim under the policy was received from the hospital for cashless treatment. The complainant was admitted on 29.7.2017 at Columbia Hospital Patiala with the provisional finding hepatitis and the complainant applied for the cashless facility for the above mentioned hospitalisation. Upon receipt of the cashless request along with the cashless request form, the OP vide letter dated 29.7.2017 and 30.7.2017 sought for providing initial assessment sheet during admission, investigation report with vital and drug chart, OPD prescription prior to admission, but no reply was received and as such the case of the complainant was closed.  On merits, it is admitted that the complainant took the policy in question.  But, since no response was received from the hospital authorities, as such the claim of the complainant was closed.

 

3.             Record shows that OP number 2 was proceeded against exparte.

 

4.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-14 copies of documents and closed evidence. On the other hand, the learned counsel for the OP number 1 has produced Ex.OP1/1 to Ex.OP1/12 copies of documents and affidavit and closed evidence.

 

5.             We have carefully perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties. None of the parties filed written submissions.

 

6. It is admitted fact between the parties that the complainant had obtained a health insurance policy from OP number 1 on 14.6.2017 from Sangrur and paid an amount of Rs.13,904/- as premium to the OP number 1 and the validity of the policy was from 14.6.2017 to 13.6.2018. During the subsistence of the insurance policy, the complainant suffered from abdominal pain problem and was admitted in the hospital on 29.7.2017 and remained admitted upto 30.7.2017. The complainant submitted the cashless claim to the hospital, which was denied by the OP number 1. Further the necessary documents to claim the refund of Rs.13,241/- was submitted to OP number 1, which was also denied by the OP number 1. Though the OP number 2 remained exparte, but submitted the statement of objections to the complaint. In the statement of objections submitted by OP number 2, it has been admitted that the cashless facility was denied to the complainant and the complainant himself paid Rs.13,241/- to OP number 1. From the documents submitted by OP number 2, it has been observed that OP number 2 along with the objections submitted discharge summary and the detail of the indoor bills of the complainant on 6.6.2018 and the same were handed over to OP number 1, but till date, OP number 1 did not settle the claim of the complainant though OP number 1 had all the relevant documents for release of the claim amount. As such, we find that the OP number 1 is liable to pay the claim amount of Rs.13,241/- to the complainant.

 

7. As such, the complaint is allowed with directions to OP number 1 to pay to the complainant an amount of Rs.13,241/- along with interest @ 9% per annum from the date of filing of the complaint i.e. 24.4.2018 till realization. We further direct the OP number 1 to pay to the complainant an amount of Rs.5000/- as compensation for mental tension, agony and harassment and litigation expenses. This order of ours be complied with within 45 days from the date of receipt of copy of order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

 

Pronounced.

                        April 8, 2019.                                    

                                                       

 

                                                        (Vinod Kumar Gulati)

                                                          Presiding Member

 

 

 

                                                                (Manisha)

                                                                  Member