Haryana

Bhiwani

CC/35/2018

Manjeet - Complainant(s)

Versus

Star Health - Opp.Party(s)

in person

15 Nov 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BHIWANI.

 

                                                             Consumer Complaint No. : 35 of 2018

                                                        Date of Institution           : 27.02.2018

                                                                  Date of order                  : 15.11.2023

 

Manjeet (since deceased) through legal heirs:

1. Smt. Salma-widow of Manjeet
2. Aakst-minor son
3. Arpita-minor daughter, minors through their mother and natural guardian Smt. Salma.
4. Chameli Devi wife of Sh.Subh Ram- mother of deceased.
5. Subh Ram son of Sh. Nand Ram - father of deceased,

 

All residents of village Manheru, Tehsil and District Bhiwani.

  

           ……Complainants.

 

Versus

 

1. Star Health & Allied Insurance Co. Ltd., No.15, Sri Balaji Complex, First Floor, Whites Lane, Roy Apattah, Chennai-600014.

 

2. IRDA No.129, Star Health & Allied Insurance Co. Ltd., Branch Office Booth No.32-33, HUDA City Center, Court Road, Bhiwani-127021.

 

3. Mr. Ranbir Singh, Intermediary Code-BA0000281140, Phone No.9253347516, E-mail ID:ranbirbhatti007@gmail.com.

 

4.       Jeevan Nursing Home, Rohtak Gate, Dadri Road, Bhiwani through authorized representative.

 

…… Opposite Parties.

 

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

 

BEFORE:       Hon’ble Mrs. Saroj Bala Bohra, Presiding Member.

  Hon’ble Ms. Shashi Kiran Panwar, Member.

 

Present:-        Sh. Dharmender Malik, Advocate for complainant.

           Sh. Avinash Sardana, Advocate for OPs No.1 & 2.

           OP No.3 given up.

           OP No.4 exparte.

 

ORDER:

 

Saroj Bala Bohra, Presiding Member:

 

1.                 In brief, facts of this case are that complainant Manjeet (since deceased) had taken a health insurance policy No.P/211119/01/2017/005036 from OPs No.2 & 3 insurance company on 31.12.2016 by paying a sum of Rs.14,496/- wherein whole family of complainant including his wife Salma were covered.  Complainant has alleged that on 04.02.2017, while going to Dadri on motorcycle, near village Dhikara, complainant and his wife met with an accident and received multiple and grievous injuries. So, they were got admitted in Life Care Multispecialty Hospital, Charkhi Dadri on the same day by some unknown person. Complainant has submitted no FIR regarding the accident was lodged as it was not with any other vehicle rather due to skid of motorcycle on road. Complainant and his wife lodged claim with OP insurance company qua this accident but the said claim rejected by the OPs.   

                    Complainant has submitted that after this, he met with another accident on 01.08.2017 at about 6:00 a.m. near Dadri Gate Rohtak while on motorcycle and received grievous injuries. For which, he remained admitted in Jeevan Nursing Home, Bhiwani.  Complainant also lodged claim qua this accident but the same was also rejected by the OPs. Hence, the present complainant has been filed by complainant seeking directions to OPs to pay Rs.74,000/- + Rs.58,000/- and Rs.60,000/- under the policy coverage and also to pay harassment and litigation charges.

2.                 Upon notice, OPs No.1 & 2 appeared through counsel and tendered reply raising preliminary objections qua maintainability, estoppel, locus standi and concealment of true facts.  On merits, it is submitted that after receipt of claims in question qua the alleged treatments of complainant and his wife from Life Care Multispecialty Hospital, Charkhi Dadri, it was observed by medical team of OP company that hospitalization of the complainant and his wife were not warranted and the claim no.0429091 qua complainant, and claim no.0429096 qua wife of complainant were repudiated by the OP company and complainant was informed vide letters dated 30.03.2017 and 18.03.2017. However, at the request of complainant, OP insurance company reconsider the claims and approved claim no.0429091 for settlement in Rs.31,371/- against the claimed amount of Rs.45002/- as per terms and condition of the policy.  The second claim was approved for Rs.25,943/- against the claimed amount of Rs.34,146/-. It is submitted that OP company was/is ready to pay the said claim amount but complainant failed to turn up for the same.

                    With regard to claim of complainant for treatment from Jeevan Nursing Home, Bhiwani from 01.08.2017 to 09.08.2017, complainant not submitted required documents despite issuance of letter dated 26.12.2017 followed by reminder dated 10.01.2018, 25.01.2018 and 09.02.2018 in this regard, however, later on, he submitted some documents except cash receipt from the said hospital for claim amount of Rs.65,712/-, so this claim of complainant was also closed as no claim by the OP company. In the end, the OPs submitted for dismissal of complaint with costs.

3.                 None appeared on behalf of OP 4 despite issuance of registered notice, hence it was proceeded against exparte vide order dated 17.01.2020.

4.                 OP No.3 was given up by complainant vide his statement dated 05.03.2021.

5.                 In evidence of complainant, documents Annexure C-1 to Annexure C-4 were tendered. Thereafter, in additional evidence of complainant, documents Annexure C-5 to Annexure C-39 were tendered and closed the evidence on 21.09.2022.

6.                 In evidence of OPs No.1 & 2, affidavit Ex. RW1/A alongwith documents Annexure R-1 to Annexure R-20 were filed and closed the evidence on 03.03.2023.

7.                 We have heard learned counsel for the contesting parties and perused the record minutely. At the outset, it is admitted version of OP insurance company that they have approved claims of complainant for Rs.31,371/- against the claimed amount of Rs.45,002/- and Rs.25,943/- against the claimed amount of Rs.34,146/- but the complainant was not ready to receive the same.  From the record, it is nowhere proved as to on what basis the deduction was applied by the OP in the claimed amount so incurred on the treatment of complainants. From claim forms Annexure R-11 and Annexure R-1, it is clear that complainant lodged claim for Rs.45,002/- and Rs.34146/- respectively but the OP insurance company approved it for a lesser amount without any convincing and cogent evidence. In such circumstances, the act of OP insurance company was arbitrariness and injustice towards the complainants. Thus we are of the view that complainants are entitled to the alleged amounts sought under the aforesaid claims.

8.                 It is also admitted case of OP insurance company that they have repudiated the claim of complainant for Rs.65,712 for want of bills and some other documents. In this regard, it is pertinent to mention here that complainant vide Annexure C-30 has placed on record the details of charges i.e. Rs.65,712/- so received by Jeevan Nursing Home, Bhiwani for treatment of complainant. Further, this documents has also been placed on record on behalf of OP insurance company as Annexure R-7. The version of OP insurance company that complainant not submitted the relevant documents for process of claim despite various letters issued to him is not tenable since there was sufficient opportunity with the OP insurance company during the pendency of this complaint seeking directions to complainant for submission of these documents but they did not make such efforts which goes against their bonafide intention to resolve the claim. However the complainant has placed on record copies of bills of Annexure C-9 to Annexure C-30 and Annexures C-32, 33,36 & 39 wherefrom, it is clear that the amount so claimed by complainant was incurred on the treatment of complainant Manjeet and it was also the option with OP insurance company to get verified the bills/documents so provided by complainant from the hospital concerned but they also did not work on this aspect rather focused on repudiating the claim. Accordingly, the complainant was entitled for the said amount. The complainants being legal heirs of complainant Manjeet (deceased) are entitled to the claim amount of his share.

9.                 In view of the above, we are of the considered opinion that the OPs No.1 & 2  are deficient  and negligent in providing proper services to the complainant for which complainant(s) have to suffer monetary losses besides mental agony and physical harassment. Hence, the complaint is allowed and the OPs No.1 & 2 are directed to comply with the following directions within 40 days from the date of order:-

(i)       To pay a sum of Rs.1,12,154/- (Rs. One lac twelve thousand one hundred fifty four) to the complainants, in equal shares, qua the amount incurred on the treatment of Manjeet (deceased), alongwith simple interest @ 9% per annum from the date of filing of complaint till the actual realization.

(ii)      To pay a sum of Rs.34,146/- (Rs. Thirty four thousand one hundred fourty six) to complainant Smt. Salma for the amount incurred on her treatment, alongwith simple interest @ 9% per annum from the date of filing of complaint till the actual realization.

(iii)     To pay Rs.20,000/- (Rs. Twenty thousand) as compensation  on account of mental agony and physical harassment. 

4. To pay Rs.5500/- (Rs. Five thousand five hundred) as litigation expenses.

                    In case of default, the OPs No.1 & 2 shall liable to pay simple interest @ 12% per annum on all the aforesaid amounts for the period of default. Certified copies of the order be sent to parties free of costs, as per rules. File be consigned to the record room, after due compliance.

Announced.

Dated:15.11.2023.