Before the District Consumer Disputes Redressal Forum, Rohtak.

                                                          Complaint No. : 339.

                                                          Instituted on     : 03.08.2015.

                                                          Decided on       : 20.04.2016.

Sunil Kumar s/o Sh.Sumer Singh R/o H.No.581/15 Saini Pura, Opp. Subhash Cinema, Rohtak.

                                                          ………..Complainant.

                             Vs.

Royal Sundaram Alliance Insurance Company Limited,  Corporate Accident & Health Department, Vishranthi Melaram Towers No.2/319 Rajiv Gandhi Salai(OMR) Karapakkam, Chennai through its Managing Director.

                                                          ……….Opposite parties.

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

BEFORE:  SH.JOGINDER KUMAR JAKHAR, PRESIDENT.

                   MS. KOMAL KHANNA, MEMBER.

                   SH.VED PAL, MEMBER.

Present:       Complainant in person.

                   Sh.Sameer Gambhir, Advocate for the opposite party.

                                      ORDER

SH. JOGINDER KUMAR JAKHAR, PRESIDENT :

1.                          The present complaint has been filed by the complainant with the averments that he got obtained health policy from opposite party vide policy No.IY00049536000100 for himself and his family members including his wife Smt. Seema and children i.e. daughter Mannat and son Aarav through online process. The insurance policy was for a sum of Rs.200000/-. It is averred that at the time of obtaining the insurance policy the complainant and his family members were quite healthy. It is averred that on 26.04.2015 the condition of the daughter of complainant aged 6 years was deteriorated and she was got admitted in Sanghi Nursing Home and remained admitted there upto 30.04.2015. It is averred that an amount of Rs.12000/- were spent in the hospital as treatment charges and Rs.710/- as test charges , Rs.1714/- on medicines and Rs.500/- as consultation charges and as per policy an amount of Rs.500/- per day is being provided for food and bed charges for hospital to patient, hence amount on this account comes to Rs.2500/-. It is averred that total claim of the complainant comes to Rs.17424/- and he duly informed the opposite party and submitted all the documents for obtaining the insurance claim.  But the complainant was shocked to receive the letter dated 03.07.2015 from the opposite party whereby the opposite party refused to pay the genuine claim of the complainant on the ground that the claim submitted by the complainant was fraudulent. It is averred that the act of opposite party of repudiating the lawful claim is illegal and amounts to deficiency in service. As such it is prayed that the opposite party may kindly be directed to pay the amount of Rs.17424/- alongwith interest, compensation and litigation expenses.

2.                          On notice, opposite party appeared and filed its written statement submitting therein that the complainant had intimated the opposite party of a claim for hospitalization of his daughter at Sanghi Nursing Home, Rohtak from 26 April 2015 to April 30, 2015 as she was allegedly diagnosed for stomach pain and vomiting. It is averred that there is a clear violation in terms of policy condition as the points mentioned in the policy are not fulfilled so as to receive the various benefits of the policy. It is averred that opposite party appointed the investigator and on the basis of report of investigator it was found that the complainant has made a fraudulent claim and therefore the claim was rightly rejected by the company through a repudiation letter dated July 3, 2015.  As such it is prayed that the complaint may kindly be dismissed with costs. 

3.                          Both the parties led evidence in support of their case.

4.                          Ld. Counsel for the complainant in his evidence tendered affidavit Ex.PW1/A and documents Ex.P1 to Ex.P27 and has closed his evidence. On the other hand, Ld. counsel for the opposite party tendered affidavit Ex.RW1/A, documents Ex.R1 to Ex.R3, Ex.R3/A to Ex.R3/G and Ex.R4 to Ex.R5 and has closed his evidence.

5.                          We have heard ld. counsel for the parties and have gone through material aspects of the case very carefully.

6.                          In the present case it is not disputed that as per policy Ex.P15, the complainant and his family members were insured with the opposite party for the sum insured Rs.200000/-. It is also not disputed that the daughter of the complainant Ms.Mannat Saini was diagnosed from Sanghi Nursing Home as is proved from the discharge Card Ex.P3. Complainant has also placed on record test reports Ex.P4 to Ex.P6 and various bills Ex.P7 to Ex.P12 to prove that the amount was spent on the treatment of  his daughter. After the treatment, complainant filed the claim with the opposite party but the opposite party vide its letter Ex.P13 had repudiated the claim on the ground that the medical records submitted by the complainant were fabricated for making fraudulent claim by using fraudulent means to device and make unlawful gain.

7.                          After going through the file and hearing the parties it is observed that the opposite party has repudiated the claim on the basis of report of investigator on the ground that the complainant has filed the fraudulent claim to obtain the benefit under the policy and that the Sanghi Nursing Home does not come under the preview of a hospital. But to prove his contention opposite party has not placed on record any document. As per the discharge card Ex.P3, patient Mannat Saini was diagnosed by Dr. Anil Sagthi, MBBS Doctor Regd. No.2379 at Sanghi Nursing Home, Rohtak for the period from 26.04.2015 to 30.04.2015 and the detailed case summary and investigations have been mentioned on the discharged card. As per the test reports and bills submitted by the complainant, he spent an amount of Rs.14924/- on the treatment of his daughter Mannat and as per Additional benefit under the policy as mentioned in the policy document Ex.P17, the insured person is entitled for the Hospial cash benefit for Rs.500/- for each completed 24 hours hospitalization subject to a maximum of 20 days for an Insured person and 60 days for all insured person during the policy period and as such the Rs.2500/- have been claimed for the five days under the additional benefits. Hence from the documents placed on file, it is proved that the daughter of the complainant has got treatment and remained admitted in the hospital from 26.04.2015 to 30.04.2015, the repudiation on the aforesaid ground is not legally justified. Accordingly the complainant is entitled for the amount spent by him on the treatment of his daughter.

 8.                        In view of the facts and circumstances of the case, it is directed that opposite party shall pay the amount of Rs.17424/-(Rupees seventeen thousand four hundred twenty four only)  along with interest @ 9% p.a. from the date of filing the present complaint i.e. 03.08.2015 till its actual realization and shall also pay a sum of Rs.3500/-(Rupees three thousand five hundred only) as litigation expenses to the complainant within one month from the date of decision failing which the opposite party shall be liable to pay interest @ 12% p.a. on the awarded amount from the date of decision.  Complaint is allowed accordingly.

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

Announced in open court:

20.04.2016.

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

                                                          Joginder Kumar Jakhar, President

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

                                                          Komal Khanna, Member.

                                                                        ……………………………

                                                                        Ved Pal, Member