Haryana

Karnal

CC/331/2019

Dhiraj Kumar - Complainant(s)

Versus

The Manager Bajaj Allianz General Insurance Company - Opp.Party(s)

Sushil Kumar

17 May 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                       Complaint No. 331 of 2019

                                                        Date of instt.13.06.2019

                                                        Date of Decision:17.05.2022

 

Dhiraj Kumar son of Ram Parkash, resident of village Makroli Kalan District Rohtak at present no.5, Assandh Tehsil Assandh, District Karnal.

                                               …….Complainant.

                                              Versus

 

1.     The Manager, Bajaj Allianz General Insurance Co. 2^nd floor Bajaj Finance Building Surveyor no.208/IB, opp Nagar Road, Behind Weikfield IT Park, Viman Nagar, Pune-411014.

 

2.     Bajaj Allianz General Insurance Co. Ltd. 1^st floor, SCO no.226 Sector-12, Karnal through its Branch Manager.

 

                                                                      …..Opposite Parties.

 

Complaint Under Section 12 of the Consumer Protection Act, 1986 and after amendment Under Section 35 of Consumer Protection Act, 2019.

 

Before   Shri Jaswant Singh……President.

              Shri Vineet Kaushik…..Member

      Dr. Rekha Chaudhary…….Member

 

 Argued by: Shri Sushil Kumar, counsel for complainant.

Shri Rohit Gupta, counsel for the OPs.

 

                    (Jaswant Singh President)

ORDER:  

 

                    The complainant has filed the present complaint Under Section 12 of the Consumer Protection Act, 1986 as after amendment Under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant has obtained a Health Insurance Policy bearing no.OG-19-1000-6021-000067529 on 10.10.2018 from OPs. The installment of Rs.2643/- monthly (total around of Rs.7500/-) has been deposited by the complainant through online SBI account. The complainant is having ID card no.19-104248145A, which is valid upto 10.10.2019. On 24.10.2018, complainant met with an accident and he was shifted to Dua Multispecialty Hospital, Karnal where operation of complainant was conducted on 25.10.2018. Complainant spent an amount of Rs.73,000/- on his treatment.  After discharge from the hospital, complainant lodged the claim with the OPs for reimbursement of the said amount. Thereafter, official of the OPs has visited the house of complainant for verification. The complainant has been submitted the required documents which have been demanded by the investigator officer.  After that, complainant received a telephonic call from the OPs and he has been informed that his claim has been declined. Then complainant sent a legal notice 15.02.2019 to the OPs requesting therein for reimbursement of the amount incurred by him on his treatment but it also did not yield any result. In this way there is deficiency in service on the part of the OPs. Hence this complaint.

2.             On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability; locus standi; cause of action and concealment of true and material facts. On merits, it is pleaded that OPs have issued policy in the name of complainant, vide policy bearing no.OG-19-1000-6021-00067529 for the period from 11.10.2018 to 10.10.2019 subject to terms and conditions of the policy. The complainant had intimated a claim with OPs by submitting claim documents in support with the claim from on account of the alleged accident, and the same was registered as claim no.OC-19-1002-6021-000010282. The alleged claim of the complainant has been duly processed by OPs and the same stands repudiated, vide repudiation letter dated 05.02.2019 on the detailed scrutiny of claim documents submitted by the complainant, it has been found by OPs that the claim does not fall under the purview of the policy for reason given below:-

“Verification of the claim document reveals the aforesaid claimant was hospitalization for the treatment of C6-C7 prolapse intervertebral dise. We have noticed certain discrepancies and non-cooperation due to which the claim stands repudiated.

It is further denied that the complainant was shifted to Dua Multispecialty Hospital, Karnal and operation of complainant was conducted on 25.10.2018 there and an amount of Rs.73,000/- has been incurred on the treatment of complainant. It is also denied that complainant met with an accident on 24.10.2018. There is no deficiency in service on the part of the OPs and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Complainant has tendered into evidence his affidavit Ex.CW1/A, copy of health and Wellness Card Ex.C1, copy of admission slip Dua Multispecialty Hospital Ex.C2, copy of medical treatment Ex.C3 to Ex.C8, copy of legal notice dated 15.02.2019 Ex.C9, postal receipt Ex.C10 and closed the evidence on 16.01.2020 by suffering separate statement.

5.             On the other hand, learned counsel for OPs have tendered into evidence affidavit of Saurav Khullar, Legal Claim-Assistant Manager Ex.OP1/A, copy of repudiation letter Ex.OP1, copy of insurance policy Ex.OP2, copy of discharge summary Ex.OP3, copy of MRI report Ex.OP4, copy of claim form part A Ex.OP5, copy of claim form part B Ex.OP6 and closed the evidence on behalf of OPs on 21.10.2021 by suffering separate statement.

6.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that complainant has obtained a Health Insurance Policy from OPs. On 24.10.2018 during the subsistence of the insurance policy, complainant met with an accident and he was shifted to Dua Multispecialty Hospital, Karnal where operation of complainant was conducted on 25.10.2018 and complainant has spent an amount of Rs.73,000/- on his treatment.  After discharge from the hospital, complainant lodged the claim with the OPs for reimbursement of the said amount but OPs did not pay the same and repudiated the claim of the complainant on the false and frivolous ground. Hence, prayed for allowing the complaint.

8.             Per contra, learned counsel for the OPs, while reiterating the contents of written version, has vehemently argued that the claim of the complainant has been duly processed by OPs and the same stands rightly repudiated, vide repudiation letter dated 05.02.2019. Hence, prayed for dismissal of the complaint.

9.             We have duly considered the rival contention of the parties.

16.           Admittedly, the complainant has purchased a Health Policy from OPs.

9.             The claim of the complainant has been repudiated by the OPs, vide repudiation letter Ex.OP1 dated 05.02.2019 on the ground reproduced as under:-

“On detailed scrutiny of the same, we found that the claim does not fall under the purview of the policy for reasons given below:-

“Verification of the claim document reveals the aforesaid claimant was hospitalization for the treatment of C6-C7 prolapse intervertebral dise. We have noticed certain discrepancies and non-cooperation due to which the claim stands repudiated.

The relevant clause of the policy is give below for your reference:

ConditionD1

Condition Precedent-Where this policy requires you to do or not to do anything, then the complete satisfaction of that requirement by your or someone claiming on your behalf is a precondition to any obligation. We have under this policy, It you or someone claiming on your behalf fails to completely satisfy that requirement, then we may refuse to consider your claim.

Hence, we regret to inform you that the claim is inadmissible and thus repudiated.

 

10.           The claim of the complainant has been repudiated by the OPs on the ground that certain discrepancies were found in the medical record of the complainant and non-cooperation of complainant. OPs have specifically denied the fact that the complainant was shifted to Dua Multispecialty Hospital, Karnal and operation of complainant was conducted on 25.10.2018 and an amount of Rs.73000/- has been incurred on the treatment of complainant. It is also denied that complainant has met with an accident on 24.10.2018. To rebut the plea taken by the OPs, complainant has not placed on record any cogent and convincing evidence.  Furthermore, as per version of the complainant, he has spent Rs.73,000/- on his treatment, but to prove the same, the complainant has not placed on record the medical bills. The onus to prove his case, was relied upon the complainant but complainant miserably failed to prove his case by leading cogent and convincing evidence. Neither the doctor who had treated the complainant nor any employees of the said hospital has been examined by the complainant to prove his version. Hence, present complaint is devoid of any merits and same deserves to be dismissed.

11.           Thus, as a sequel to abovesaid discussion, we found no merits in the complaint and same is hereby dismissed. No order as to costs. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Dated:17.05.2022

                                                                       

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

 

(Vineet Kaushik)        (Dr. Rekha Chaudhary)      

      Member                       Member