Smt. Bina Choudhuri............Ld. Member.

The Complainant has filed this case against the OP’s and prays for the following order/reliefs:-

1. Direction against the OP’s to pay a sum of Rs.1,72,786/- to the complainant.
2. Direction against the OP’s to pay a sum of Rs. 1,50,000/- to the complainant for harassment and mental agony.
3.  Direction against the OP’s to pay a sum of Rs.70,000/- as litigation cost to the complainant.
4. Any other relief which the complainant is entitled.

Brief Fact Of The complaint

1. That the complainant purchased a mediclaim policy being in no 00000000004737941-02 from the OP no1, policy was valid from 17.07.2018 to 16.07.2019.
2. The complainant due to his illness admitted in the “SRI GANGA RAM HOSPITAL”, New Delhi for his treatment on 16.11.2018 and he was discharged therefrom on 21.11.2018 and after treatment the complainant submitted all the documents, to the OP no.3.

The OP’s without handing over any acknowledgement receipt verbally assured that the complainant will get the claim amount within thirty days.

3.  That when the OP’s did not pay the claim amount the complainant again handed over documents to the OP no.3 on 14.01.2020 but again the officials refused to issue any acknowledgement. But the OP’s paid no heed to the complainant for   settlement of the claim and thereafter the complainant sent legal notice to the OP’s through his Ld. Advocate on 20.09.2019.
4. That, on 14.11.2019 the OP’s replied to the complainant through their Ld. Advocate stating the repudiation of the claim.
5. That, nonpayment of the claim amount is example of deficiency in service and unfair trade practice on the part of the OP’s.
6.  That the cause of action of the case arose on 14.11.2019 when the Ld. Advocate of the OP’s issued letter intimating the complainant regarding repudiation of the claim.
7.  That due to such deficiency in service and unfair trade practice on the part of the OP. the complainant is suffering from mental pain as well as financial loss.

            Notice was issued from this commission and on receipt on notice the OP’s appears, filed written version and denied all the material allegation of the complainant. The OP’s in the written version have stated that, the Paragraph No. 2, 3, 4, 7, 9 and 10 of the plaint are matter of record and the OP’s have denied the Paragraph No. 1, 5, 6, 8, 10 to 16 and 18 to 25 of the plaint.

          The OP’s have also stated that the complainant has filed this case without providing any supportive documents and with malafide intension he filed this case and the complainant is not entitled to get any relief as prayed for and they praying for dismissal of this case.

          The complainant has filed the photocopy of Policy document, Legal notice, Medical prescription along with medical bills.

          Having heard the Ld. advocate of both the side and on perusal of the complaint, written version as well as documents filed by the parties the following points are taken to be considered/decided by this Commission.

POINTS FOR CONSIDERATION

1. Whether the complainant is a consumer as per the provision of C.P. Act. ?
2. Whether the case is maintainable in its present form and prayer under the provision of the C.P. Act. ?
3. Whether there is any cause of action to file this case by the complainant?
4. Whether there was deficiency in service on the part of the OP as alleged by the complainant?
5. Is the complainant has able to prove this case and entitled to get any relief as prayed for?

DECISION WITH REASONS

All the points are taken up together for discussion to avoid unnecessary repetition and for sake of convenience and brevity of this case.

To prove the case the complainant has filed written deposition in the form of an affidavit and also filed some documents by a firisti.

At the time of argument Ld. Advocate of the complainant has stated that the complainant has been able to prove the case against the OP’s through the evidence of the complainant. He also argued that within the policy period the complainant was admitted in the “Sri Ganga Ram Hospital, New Delhi” on 16.11.2018 and was discharged therefrom on 21.11.2018. He further argued that, in the written deposition the complainant has specifically corroborated the contents of the complaint with regard to admission in the Hospital, medical expenditure, submission of claim form with the OP’s. He further argued that, in reply to the Legal Notice the OP’s have admitted the fact of admission of the petitioner in the Hospital as well as submission of the claim form with the OP’s. Ld. Advocate of the complainant has also argued that the complainant on several occasion requested the OP’s for settlement of the claim but they did not pay any heed to that and they harassed the complainant by not settling the claim and the same is nothing but the unfair trade practice as well as clear deficiency in service on the part of the OP’s. He praying for necessary order in this regard.

Ld. Advocate of the OP’s by filing written notes of argument disclosed that the complainant has failed to prove the case against the OP’s and the complainant has filed this case against them to extort huge amount of compensation. He further argued that by making reply against the Legal Notice of the Complainant the OP’s have asked the complainant to supply the documents required for assessing the claim of the complainant but the complainant did not provide the required documents/information to the OP’s but the complainant did not provide the same. He further argued that, there was no deficiency in service as well as unfair trade practice on the part of the OP’s and he praying for dismissal of the case.

Having heard the Ld. Advocate of the parties and on perusal of the entire record it reveals that, the complainant has been able to prove the fact that, he was a consumer under the OP’s and he purchased  a Health Insurance Policy bearing  in No. 000000004737941-02 form the OP No. 1 and the said fact is admitted by the OP’s.

It is also admitted fact by both the parties that, the said Health Insurance Policy was valid from 17.07.2018 to midnight of 16.07.2019.

It is also not denied by the OP’s that the complainant was not admitted in the “Sri Ganga Ram Hospital, New Delhi” from 16.11.2018 to 21.11.2018 i.e. within the effective period of Insurance Policy.

It is also admitted fact by both the parties that, the complainant raises a reimbursement claim with the OP’s bearing claim No. T121218961 for reimbursement of medical expenditure. It is also admitted fact by the parties that till today the claim of the complainant has not been settled.

From the written version of the OP’s and from the written notes of argument it is also admitted by the OP’s that the complainant sent Legal Notice to the OP’s which was received by them and in reply to that notice the OP’s have replied that the claim of the complainant was not settled due to non supply of relevant documents/information. But form the instant case record it reveals that, the complainant has filed the Health Insurance Policy Documents, Medical Prescription, Medical Bills for the sum of Rs. 1, 72,786/-.

It is needless to mention here that, the medical Reimbursement claim of the complainant has neither been settled nor repudiated by the OP’s till today. On the other hand it is basic Principal of the Health Insurance Policy that, the claimant will be entitled for reimbursement of medical expenses within the effective policy period if he/she incurred medical expenditure. But in the case in hand no medical expenditure was given to the complainant though he raised reimbursement claim from the OP’s and not settling of medical reimbursement claim within the effective Policy period is nothing but the deficiency in service as well as restrictive trade practice on the part of the OP’s.

Accordingly we are of the view that, the complainant has been able to prove its case against the OP’s and all the OP’s are jointly and severally liable to pay the awarded amount to the complainant.

Hence, it is therefore,

O r d e r e d

That, the instant Consumer Case being in No. 13/2020 is hereby allowed on contest but in part. The OP’s are directed to pay a sum of Rs. 1,72,786/- (Rupees one lakh seventy two thousand seven hundred eighty six) only to the complainant towards reimbursement of Medical expenditure.

The OPs are also directed to pay a sum of Rs. 20,000/- (Rupees twenty thousand) only to the complainant for mental pain, agony, harassment as well as for deficiency in service on the part of the OP’s.

The OP’s are further directed to pay a sum of Rs. 10,000/- (Rupees ten thousand) only to the complainant as litigation cost and OP’s are further directed to pay a sum of Rs. 10,000/- (Rupees ten thousand) only to the Consumer Legal Aid Account of this Commission.

The OP’s are directed to pay the entire amount within one month from this day failing which the OP’s will have to pay interest @ 9 % per annum till making payment of the entire amount.

Let a copy of this order be given to the parties free of cost.