Before the District Consumer Disputes Redressal Forum, Rohtak.
Complaint No. : 296.
Instituted on : 15.05.2017.
Decided on : 15.05.2019.
Vikas son of Sh. Tara Chand, age 38 year, R/o H.No. 462/13, Tej Colony, Rohtak.
………..Complainant.
Vs.
1. Star Health and Allied Insurance Company Limited
1, New Tank Street, Valluvar Kottam High Court,
Nungambakkam, Chennai-600034.
2. Star Health and Allied Insurance Company Limited
-
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
SH. VED PAL, MEMBER.
DR. RENU CHAUDHARY, MEMBER.
Present: Sh. Kulvinder Singh, Advocate for the complainant.
Sh. Gulshan Chawla, Advocate for opposite parties.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case are that the complainant had obtained Family Health Optima Insurance Plan HDFC Health Plan through official of respondent No. 2 which commenced from 26.05.2016 bearing policy No. P/211118/01/2017/000520 of sum assured Rs. 5,00,000/- and Rs. 8032/- was paid by complainant as premium. That on 28.05.2016, the complainant was met with an accident and got his left elbow injured badly. Thereafter, the complainant was admitted in Sunflag Hospital on same day and was operated. Then the complainant informed to respondent No. 2 about the incident and advisor of respondent No. 2 visited at hospital and told the complainant that respondent No. 2 has assured to make all the arrangement regarding the hospital bill. On 29.05.2016, the complainant was got operated of his left elbow and was discharged on 31.05.2016 from the hospital, but the respondent No. 2 did not pay the bill of complainant to the hospital. After that the complainant cleared all his dues towards the hospital and pay approx. Rs.1,00,679/- to the hospital and submitted the same to respondent No.2 alongwith claim form. It is alleged that after one month, complainant received information about the rejection of claim on the basis of report of investigator. Complainant made so many requests to the opposite parties and lso sent a legal notice to the respondents, but they refused to pay any heed. That the act of opposite parties is illegal and there is deficiency in service on the part of opposite parties. As such, it is prayed that opposite parties may kindly be directed to pay Rs.100679/- alongwith interest @ 9% p.a. from the date of withholding the same till realization, Rs. 22,000/- as compensation alongwith Rs. 11,000/- as litigation expenses to the complainant as explained in relief clause.
2. After registration of complaint, notice was issued to the opposite parties. Opposite parties No. 1 and 2 in their reply has submitted that it is observed that the complainant was admitted in the network hospital but he has not raised any pre-authorization request for cashless facility. It is further submitted that the insured person failed to produce authenticated information like description of auto-rickshaw to which the bike registration No. HR-13A-8783 collided, names of the witnesses and lodging of FIR etc. The bike has no signs of damage due to the alleged accident. It is further submitted that the brother of the patient took the patient to the hospital, but could not inform exactly the date and time of the accident to the claim verification officer. It is further submitted that the shopkeepers of the area clearly intimated to claim verification officer that no such accident took place in the area for quite a long period. It is further submitted that the policy is only 2 days old at the time of admission of the patient for the diagnosis. The complainant has intimated the claim only on 03.06.2016, which is a violation of condition No. 2 of the policy issued to the complainant, as claim intimation with full particulars shall be sent to the company within 24 hours from the date of occurrence of the event. All the other contents of the complaint were stated to be wrong and denied and opposite parties No. 1 and 2 prayed for dismissal of complaint with cost qua the opposite parties No. 1 and 2.
3. Ld. counsel for the complainant in his evidence has tendered affidavits Ex.CW1/A and Ex.CW2/A, documents Ex.C1 to Ex.C18 and has closed his evidence on dated 04.12.2018. Learned counsel for the opposite parties in his evidence has tendered affidavit Ex.RW1/A and documents Ex.R1 to Ex.R12 and has closed his evidence on dated 23.04.2019.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. In the present complaint, the claim of the complainant has been repudiated vide letter dated 31.03.2017 placed on record as Ex.C16 on the ground that the complainant had failed to produce any authenticated information like description of auto rickshaw to which the bike collied, names of witnesses, lodging of FIR etc., that there was no logic of admitting in a distant hospital for the accidental injury in an emergency. Respondent also taken the plea that in the discharge summary they found overwriting of a date and also mentioned so many other grounds in the alleged letter.
6. It is well proved through the policy Ex.C2 that the period of policy was 26.05.2016 to 25.05.2017. The perusal of the documents also establish that accident took place on 28.05.2016 and the insured patient was operated on 29.05.2016 regarding the injuries. The respondent himself placed on record documents Ex.R6 and Ex.R7, the photocopies of the X-Ray report, which itself shows that the complainant suffered huge injuries in his leg and he was operated by the doctors which was proved through the discharge summary itself. Moreover, the respondent officials also placed on record Ex.R4 a claim form which was forwarded by Dr. Kapil Sangwan before the insurance company and the expenditure of Rs.99783/- was incurred by the complainant whereas the complainant has demanded an amount of Rs.100679/- through this complaint. We have perused all the documents placed on record by both the parties and has observed that admission and discharge of the complainant from 28.05.2016 to 31.05.2016 is well proved. The expenditure is also well proved from bills Ex.C10 to Ex.C14 & Ex.C17. Hence the claim has been repudiated by the opposite parties on flimsy grounds which is illegal and unjustified and the complainant is entitled for the claim amount as mentioned in the claim form Ex.R4.
7. In view of the facts and circumstances of the case, complaint is allowed and we hereby direct the opposite parties to pay a sum of Rs.99783/-(Rupees ninety nine thousand seven hundred and eighty three only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 15.05.2017 till its realization and shall also pay a sum of Rs.5000/-(Rupees five thousand only) as compensation on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.
8. 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:
15.05.2019.
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Nagender Singh Kadian, President
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Ved Pal, Member.
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Renu Chaudhary, Member.
