Haryana

Bhiwani

CC/129/2022

Satish Kumar - Complainant(s)

Versus

Star Health - Opp.Party(s)

In person

21 Dec 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BHIWANI.

 

                                                             Consumer Complaint No. : 129 of 2022

                                                        Date of Institution           : 27.06.2022

                                                                  Date of order                  : 21.12.2023

 

 

Satish Kumar son of Shri Ganpat Ram R/o H.No.7, Nai Basti Meham Road, Bhiwani, Tehsil and District Bhiwani.

  

           ……Complainant.

 

Versus

 

1. Star Health & Allied Insurance Co. Ltd., Branch office at SCF-47, Panchayat Pocket, Opp. Red Cross, Bhiwani, Tehsil and District Bhiwani through its authorized signatory.

 

2. Khalsa Management Hospital, situated in Churnamani Hospital Complex, Delhi Road, Camp Chowk, Hisar through its authorized signatory.

 

…… Opposite Parties.

 

COMPLAINT U/S 35 OF CONSUMER PROECTION ACT, 2019.

 

BEFORE:       Mrs. Saroj Bala Bohra, Presiding Member.

  Ms. Shashi Kiran Panwar, Member.

 

Present:-        Complainant in person.

           Sh. Avinash Sardana, Advocate for OP No.1.

           OP No.2 exparte.

 

 

ORDER:

 

Saroj Bala Bohra, Presiding Member:

 

1.                 In brief, facts of this case are that complainant had taken a Family Health Optima Insurance policy No.P/211128/01/2022/000136 from OP No.1 insurance company in the year 2017 and since then the same is regular. On 11.02.2022, complainant got himself tested in a private lab and incurred Rs.200/- but the amount was not paid him OP. Further, on 12.02.2022, he suffered abdomen pain and was taken to OP No.2 hospital and incurred a sum of Rs.6150/- on his treatment, medicines including medical tests. However, OP No.1 paid him only Rs.3400/- but the remaining amount of Rs.2750/- was not paid. On 13.02.2022, complainant was got admitted again in OP No.2 hospital and he was operated there and discharged on 14.02.2022 and incurred Rs.48,404/- on this treatment.  Complainant admitted that the bills was passed by the OP No.1. 

                    Complainant has submitted that on 12.03.2022, he got checked in the Op No.2 hospital has to incur Rs.7175/- on treatment, medicines and testing but  OP No.1 paid him only Rs.4675/- and not paid the remaining amount of Rs.2500/-. Thus the complainant has alleged that Rs.5450/- was not paid by the OP No.1 insurance company towards his medical expenses despite many requests. Hence, the present complaint has been preferred by complainant alleging deficiency in service and negligent behavior of OP resulting into monetary loss as well as mental and physical harassment. As such, complainant has sought directions of this Commission against the OP No.1 to pay Rs.5450/- alongwith interest @ 18% per annum from the date of due till actual realization. Further to Pay Rs.2.00 lac towards harassment. Any other relief to which this Commission deems fit has also been sought.

2.                 Upon notice, OP No.1 appeared through counsel and admitted that complainant including his family members were insured with OP No.1 for Rs.10.00 lac w.e.f. 26.04.2021 to 25.04.2022 subject to certain terms and conditions of the policy. The OP No.1 has admitted that the deductions as alleged by complainant were under the terms & conditions of the policy which is bindig upon both the parties.  In the end, deficiency in service or any negligence has been denied and prayed for dismissal of the complaint with costs.

3.                 None appeared on behalf of OP No.2 despite issuance of registered notice, hence it was proceeded against exparte vide order dated 04.10.2022.

4.                 In evidence of complainant, his affidavit Ex.CW1/A alongwith documents Annexure C-1 to Annexure C-11 were tendered and then closed the evidence.

5.                 In evidence of OP No.1 affidavit of Mr. Sumit Kumar Sharma as Ex. RW1/A alongwith documents Annexure R-1 to Annexure R-12 were filed and closed the evidence.

6.                 We have heard the complainant, learned counsel for contesting OP and perused the record.

7.                 It is admitted case of complainant that he has received part payment of medical expenses from OP No.1 insurance company and now only remains unpaid amount as Rs.5450/-.  The amount has been deducted by the OP insurance company on account of pre-hospitalization and post-hospitalization expenses and for some other items which allegedly are not covered under the policy. Perusal of terms and condition of insurance policy placed on record as Annexure R-3 reveals that Pre-hospitalization and Post-hospitalization are admissible to the insured person and thus the case of complainant is covered under the insurance policy and the OP No.1 has wrongly and illegally denied the amount to complainant.  In this regard,  the case law delivered by Hon’ble Punjab & Haryana High Court in CWP No.26178 of 2016 titled as National Insurance Co.Ltd. Vs. Sandeep & others reported in 2017 (1) RCR (Civil) Page 621 in of much significance wherein it has been  held that “Insurance companies give lucrative offers to attract customers-However, the moment any insured puts even the most genuine claim, seldom said claim would be accepted by any insurance company.”

8.                 Accordingly, the OP No.1 is negligent and deficient in providing proper services to the complainant which caused monetary loss as well mental and physical harassment to him. As such, the complaint is allowed and OP No.1 insurance company is directed to comply with the following directions with 30 days from the date of passing of this order:-

(i)       To pay a sum of Rs.5450/- (Rs. Five thousand  Four hundred fifty) to the complainant.

(ii)      To pay a sum of Rs.5,000/- (Rs. Five thousand) on account of harassment as well as litigation expenses.

                    Further the award in question/directions issued above must be complied with by the OP No.1 within the stipulated period failing which all the awarded amounts  shall attract simple interest @ 9% per annum for the period of default. 

                    If this order is not complied with, then the complainant shall be entitled to the execution petition under section 71 of Consumer Protection Act, 2019 and in that eventuality, the opposite party may also be liable for prosecution under Section 72 of the said Act which envisages punishment of imprisonment, which may extend to three years or fine upto rupees one lac or with both.  Copies of this order be sent to the parties concerned, free of costs, as per rules.  File be consigned to the record room after due compliance. 

Announced.

Dated:21.12.2023.

 

                              (Shashi Kiran Panwar)              (Saroj Bala Bohra)

                                                   Member                 Presiding Member

District Consumer

Disputes Redressal

Commission, Bhiwani. 

 

 

Present:-        Complainant in person.

           Sh. Avinash Sardana, Advocate for OP No.1.

           OP No.2 exparte.

 

                    Arguments heard. Vide our separate order of even date, the complaint has been allowed.  File after due compliance be consigned to the record room.

 

Dated:21.12.2023.

 

                              (Shashi Kiran Panwar)              (Saroj Bala Bohra)

                                                   Member                 Presiding Member

DCDRC, Bhiwani.