Haryana

Fatehabad

CC/177/2018

Anshul - Complainant(s)

Versus

star Health Insurance - Opp.Party(s)

Amit Wadhera

27 Jan 2023

ORDER

FBEFORE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, FATEHABAD.

                                                           Complaint Case No.: 177 of 2018.                                                                     Date of Institution:    18.06.2018                                                 Date of order:                   27.01.2023.

Anshul son of Sh.Vinod Kumar Dudeja resident of Lorentz Public School Wali Gali, R.K.Colony, Fatehabad District Fatehabad.

                                                                          ….. Complainant.

                                          Versus     

 

1.Star Health & Allied Insurance Company Limited through its Branch Manager, Ground Floor Rathore Towers, Near Hotel Mehak Dabwali Road, Sirsa-125055 (insurer of complainant vide medical Policy( Family Health Optima Insurance Plan) No.P211121/01/2018/000108 having validity from 20.04.2017 to 19.04.2018.

2.Amit Nagpal, Office situated at back side of Papiha park, near Pardeep Mukhi residence Model Town, Fatehabad District Fatehabad (agent of respondent no.1)

….Opposite parties.

Complaint U/s 12 of the Consumer Protection Act    

BEFORE:    Sh. Padam Singh Thakaur,President.                                             Sh.K.S.Nirania,Member.                                                                  Smt. Harisha Mehta,Member.

Present:          Shri Amit Wadhera, Advocate for the complainant.                            Shri Sachdev Bishnoi, Advocate for the OP No.1.                                  Shri Sudhir Narang, Advocate for OP No.2.

 

 

ORDER:

                             Present complaint has been filed for the payment of medical bills of complainant which have not been paid by the company against the Family Health Optima Insurance Plan no. P211121/ 01/2018/000108 valid from 20.04.2017 to 19.08.2018 which was taken through Op No.2. Initially, the complainant had taken treatment at Sehgal Hospital from 27.09.2017 to 30.09.2017 and also submitted the bills to the sum of Rs.25,000/-  to the Ops for the taken treatment at Fatehabad. The complainant again got treated from Dr.Kapil Jain from 09.10.2017 to 15.10.2017 at Hisar and the management of the hospital had charged approximately Rs.60,000/- from the complainant and thereafter the complainant had taken treatment form Appollo Hospital, Sarita Vihar, New Delhi and the doctor had issued the bill to the sum of Rs.1,43,354/-  which was to be paid by the insurance company to the hospital but the insurance company paid the amount in question to the complainant 17.06.2019 after the filing of the present complaint.

2.                          Both the parties contested the complaint by filing their separate replies. The OP N.1 in its written statement has taken several preliminary objections such as maintainability and concealment of material etc. On merits, it has been submitted that the complainant himself has not submitted the claim documents for reimbursement of the claim. It has been admitted that the complainant had taken treatment from various hospitals  but despite issuance of several reminders the complainant had not submitted the original bills, receipts alongwith other documents which were required as per Condition no.4 of the policy.  Other contentions have been denied and prayer for the dismissal of the complaint has been made.

3.                          Op No.2 in its separate reply has taken many preliminary objections such as jurisdiction, limitation, concealment of material facts and the complainant does not fall within the definition of consumer. On merits, the answering Op has admitted that the complainant had purchased the policy and it has also been admitted that the complainant has also taken treatment from different hospitals. Rest of complaint are denied and prayer for dismissal of the complaint has been made.

4.                          The parties led their respective evidence. The complainant has tendered affidavit  Ex.C45 and documents Ex.C1 to Ex.44 Whereas the Ops have tendered affidavit Annexure R1/A and documents Annexure R1 to Annexure R31.

5.                 We have heard learned counsel for the parties and have perused the case file carefully.

6.                Learned counsel for the complainant contented that the company has paid Rs.1,42,340/- on 17.06.019 after 20 months vide Annexure C43. Further, conceded that the company had also paid Rs.13,711/- on 07.12.2019 after approximately 26 months vide Annexure C44. It has been further argued that the complainant out of the total bills now, Rs.62563/- (after deducting Rs.8000/-) which was paid by the insurance company to the hospital  at Hisar, is outstanding against the company and prayed for the payment of outstanding bill alongwith interest for late payment of previous bills.

7.                          On the other hand, the counsel for Op No.1/insurance company contended that complainant has no cause of action to file the present complaint because the company has already paid the bills to the complainant on 17.06.2019 and 07.12.2019, therefore, there is no deficiency in service and unfair trade practice on the part of the insurance company. Learned counsel for the Ops prayed for dismissal of the complaint.  

8.                          From the perusal of record placed on the file, it is clear that the complainant had purchased the policy Ex.C1 from the Op No.1. It is admitted fact by the parties that the complainant had taken treatment from various hospitals such as Fatehabad and thereafter Hisar and in the last from hospital situated at Delhi. It is also on the record that the OP had paid the  part payment of the bills for the treatment taken at Fatehabad and Delhi and only the payment to be made by the company is for the bills issued by Hospital at Hisar to the sum of Rs.55407/- as evident from Annexure C19. He has also purchased the medicine from the market to the sum of Rs.15,156/- as per annexure C21 to Annexure C28. The medical expenses in the sum of Rs.70563/- were borne by the complainant at Hisar but the insurance company had only made the payment of Rs.8000/- only on 15.10.2017 as is evident from Annexure C20.  From the contentions as well as from the record placed on the file, it is clear that now Rs.62543/- is outstanding against the Op No.1/insurance company which  the company is liable to pay alongwith interest 6 @ per annum from the date of bills submitted by the complainant to the company  i.e. 21.10.2017 when the complainant was discharged from the hospital.

9.                Thus, as a sequel to ou´r above discussion, we accept the present complaint  and direc|{}

t the OP No.1/insurance company to pay the amount of Rs.62,563/- spent as medical expenses at Hisar to the complainant alongwith interest @ 6% per annum. Further the Op No.1/insurance company is directed to pay composite compensation to the sum of Rs.25,000/- on account of interest, mental agony, harassment as well as litigation expenses. This order should be complied within a period of 45 days from the date of this order, failing which the complainant will be entitled to interest @ 9 % per annum for the default period. A copy of this order be supplied to the parties free of costs. File be consigned to the record room after due compliance.

Announced in open Forum.

Dated: 27.01.2023.                                                       

                                                                    (Padam Singh Thakur)                                                                             President

(K.R.Nirania)      (Hariha Mehta)   Distt.Consumer Disputes          Member              Member                Redressal Commission,                                                                             Fatehabad.