Delhi

North East

CC/104/2021

PRAMOD KUMAR - Complainant(s)

Versus

STAR HEALTH AND ALLIED INSURANCE CO LTD - Opp.Party(s)

RAJENDRA SINGH AND VIJAY SHANKAR SHARMA

16 Mar 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

Complaint Case No. 104/21

 

In the matter of:

 

	Pramod Kumar S/o Sh. Phool Singh, R/o A-2/190/10, Amar Colony East Gokulpur, North East, Delhi-110093	Complainant
	Versus
	Star Health And Allied Insurance Co. Ltd., Through its Manager, Registered Office:- Sri Balaji Complex, 15, Whites Road, Chennai 600014   Regional Office:- 1st Floor, Himalaya House, Kasturba Gandhi Marg, New Delhi-110001.	Opposite Party

 

DATE OF INSTITUTION:       JUDGMENT RESERVED ON:                   DATE OF ORDER      :

12.08.2021 14.03.2023 16.03.2023

 

 

CORAM:

Surinder Kumar Sharma, President

Anil Kumar Bamba, Member

Adarsh Nain, Member

ORDER

Ms. Adarsh Nain, Member

The Complainant has filed the present complaint under Section 35 of the Consumer protection Act, 2019.

Case of the Complainant

1. The case of the Complainant as revealed from the record is that the Complainant had purchased a health insurance policy no. P/161100/01/2021/035767 (Young Star Insurance Policy) from Opposite Party in the name of entire family including the Complainant. It is stated that on 11.06.2021, wife of the Complainant had fallen ill and she was admitted in Panchsheel Hospital, at Yamuna Vihar, Delhi and discharged on 15.06.2021. It is also stated that the Complainant already intimated to the Opposite Party regarding the ailment and admission of the wife of the Complainant in the hospital. It is further stated that the Complainant’s wife was treated by the Panchsheel Hospitals Pvt. Ltd. at C-3/63-A, 64-A, Yamuna Vihar, Delhi-110053 for a sum of Rs. 40,816/-, which had been paid by the Complainant. The Complainant several times demanded and requested to the Opposite Party to pass the medical claim of his wife but Opposite Party did not give any satisfactory answer. On 09.07.2021, the Complainant sent a legal notice through its Counsel  through speed post to Opposite Party through his counsel which were duly received by the Opposite Party but no fruitful purpose get served and allegedly, the Opposite Party neither paid the bill amount nor replied the same. Hence, the Complainant has filed the present complaint praying to direct the Opposite Party to pay treatment amount of Rs. 40,816/-, Rs. 1,00,000/- on account of mental pain and agony and Rs. 25,000/- as litigation expenses.
2. Opposite Party was duly served at its registered office on 20.09.2021 but none appeared on their behalf. Hence, Opposite Party was proceeded ex-parte vide order dated 23.03.2022.

Ex- Parte Evidence of the Complainant

3. The Complainant in support of his complaint filed his ex parte evidence by way of affidavit wherein he has supported the averments made in the complaint. The complainant has relied upon inter alia Policy document, discharge sheet, final detailed bill alongwith the receipts Rs. 40816/-, copy of legal notice alongwith original postal receipts and track report thereof.

Arguments & Conclusion

4. We have heard the Counsel for the Complainant and perused the file record.
5. We have considered the contentions of the counsel for the complainant. The document Ex.CW1/2 which is policy document filed by the complainant shows that complainant had a valid policy subsisting for his family for a period from 02.02.2021 to 01.02.2022 for a sum insured of Rs.500000/-. The perusal of the discharge summary shows that the wife of the complainant admitted for treatment on 11.06.2021 and discharged on 15.06.2021 and  the complainant was billed for Rs.40,816/- for expenses incurred in treatment and the amount was paid by the complainant as is shown by the receipts filed by the complainant in this respect. The complainant has contended that he had intimated the Opposite Party immediately about the ailment but the said contention is not supported by any documentary evidence. However, he has placed on record the copy of legal notice and its postal receipts demanding the claim amount but Opposite Party had not replied or paid the amount in spite of receiving the notice.
6. The perusal of the policy document which contains the Policy wordings, shows that in the event of hospitalization, intimation to be given to the company immediately and the complainant contended that he had intimated immediately. Though, the complainant has not filed any document in support of his contention, however, since, it is an ex-parte case and complainant is to be given benefit of doubt as no rebuttal is there. The said contention is taken as proved.
7. In view of above discussion and the rebutted and uncontroverted testimony of the complainant regarding the deficiency of services on the part of OP, we are of the considered view that the Opposite party i.e. Star Health And Allied Insurance Co. Ltd., has been deficient in services by not paying a valid claim of the complainant.
8. Thus, we allow the present complaint and direct the Opposite party i.e. Star Health and Allied Insurance Co. Ltd. to pay to the complainant the claim amount of Rs. 40,816/-, with interest @6% per annum from the date of institution of the complaint. The Opposite Party is also directed to pay Rs. 15,000/- towards compensation and Rs.7,000/- towards litigation cost along with interest @ 6 % per annum from the date of this order till its recovery.
9. Order announced on 16.03.2023.

Copy of this order be given to the parties free of cost

File be consigned to Record Room.

(Anil Kumar Bamba)           Member

(Adarsh Nain) Member

(Surinder Kumar Sharma) President