Chandigarh

DF-I

CC/12/2024

SANJEEV KUMAR - Complainant(s)

Versus

THE MANAGER OPERATIONS Head, ADITYA BIRLA HEALTH INSURANCE - Opp.Party(s)

04 Sep 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/12/2024
Date of Institution	:	01/01/2024
Date of Decision	:	04/09/2024

 

Sanjeev Kumar, r/o 606, Sector 19, Panchkula, Haryana

… Complainant

V E R S U S

1. The Manager, Operations Head, Aditya Birla Health Insurance, 1^st Floor, SCO 2473-2474, Sector 22C, Chandigarh 160022
2. Aditya Birla Health Insurance Company Ltd., Corporate Office, 9^th Floor, One Indiabulls Centre, Tower 1, Jupiters Mills Compound, SB Marg, Elphinstone Road, Mumbai, Maharashtra 400013.

… Opposite Parties

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Sh.S.K.Verma, Adv. for Complainant (thr. VC).
	:	Sh. Gaurav Bhardwaj, Advocate for OPs

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Sanjeev Kumar, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations, as projected in the consumer complaint, that in the year 2017, complainant had purchased a health policy from the OPs and got the same renewed from time to time on payment of requisite premium.  On 6.9.2023, complainant was taken to J.P. Hospital, Zirakpur (hereinafter referred to as “treating hospital”) in unconscious condition and was admitted in emergency at around 9.30 p.m. and was discharged on the next day i.e. 7.9.2023 at around 9.33 p.m. i.e. after more than 24 hours.  Initially the complainant was given treatment in the emergency and thereafter he was shifted to the OPD ward where his admission file was opened at 11.30 p.m.  The treating hospital had raised bill of ₹14,815/- and when the complainant raised claim with the OPs, the same was repudiated on the ground that he had not completed 24 hours hospitalization and as per the terms and conditions of the policy, he is not entitled for the claim.  The complainant had approached the treating hospital for the actual hospitalization period after which it had issued the certificate which was also submitted by him with the OPs, but, even the same was not considered by the OPs. Thereafter the complainant had issued legal notice to the OPs, but, with no result. In this manner, the aforesaid act of the OPs amounts to deficiency in service and unfair trade practice. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability, cause of action and jurisdiction and also that the complainant has not acted in good faith.  However, it is admitted that the complainant had obtained the subject policy (Annexure R-1 & 2) from the OPs which was valid w.e.f. 4.11.2021 to 3.11.2023 and he had lodged claim with the OPs, but, the same was repudiated on the ground that the claim was against the terms and conditions of the policy. On merits, the facts as stated in the preliminary objections have been reiterated. It is further submitted that the complainant was admitted for treatment of diabetes mellitus with acute febrile illness on 6.9.2023 at 11.11 p.m. and was discharged on 7.9.2023 at 9.32 p.m. and since the complainant had not completed the 24 hours hospitalization, his claim was repudiated.  The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. In rejoinder, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully including written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had obtained the subject health policy (Annexure R-1 & 2) from the OPs and he rushed to the treating hospital on the evening of 6.9.2023 and was discharged on 7.9.2023 at around 9.33 p.m. and that as per the terms and conditions of the subject policy, insured/complainant was entitled for mediclaim only in case of 24 hours hospitalization, the case is reduced to a narrow compass as it is to be determined if the complainant/insured remained hospitalized in the treating hospital for 24 hours for his treatment and the OPs are unjustified in repudiating his genuine claim and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the OPs have rightly repudiated the claim of the complainant on the ground that he was not hospitalized for 24 hours and the consumer complaint of the complainant, being false and frivolous, is liable to be dismissed, as is the defence of the OPs.
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms and conditions of the subject policy, medical record and the repudiation letter and the same are required to be scanned carefully for determining the real controversy between the parties.
   3. Perusal of the discharge summary (Annexure B) annexed with the consumer complaint clearly indicates that the complainant was admitted in the treating hospital on the evening of 6.9.2023 and was discharged on the next evening of 7.9.2023.  As per the defence of the OPs, complainant was admitted in the treating hospital on 6.9.2023 at 11.11 p.m. whereas it is the case of the complainant that he was initially given treatment in the emergency on 6.9.2023 at 9.30 p.m. and was discharged on 7.9.2023 at 9.33 p.m.  This case of the complainant stands proved from the emergency certificate issued by the treating hospital (Annexure E/page 36), which clearly proves that the complainant was attended in the emergency at around 9.30 p.m. and was discharged on the next day i.e. 7.9.2023 and the relevant portion of the same is reproduced below for ready reference :-

  “This is to certify that Patient Sanjeev Kumar 40yrs/Male patient is K/C/O DM presented in emergency around 9.30pm on 06.09.2023 with c/o High Grade fever pain in abdomen, Nausea sensation, headache, vomiting body aches, uneasiness, decreased oral intake and generalized weakness. He was admitted through emergency for further management at JP Hospital and was discharged on 07.09.2023 at 09:33pm.

 

4. Thus, one thing is clear from the aforesaid emergency certificate issued by the treating hospital that the complainant remained hospitalized in the treating hospital for more than 24 hours as he was admitted/treated firstly in the emergency at around 9.30 p.m. on 6.9.2023 and discharged on 7.9.2023 at 9.33 p.m. and it is safe to hold that the OPs are unjustified in repudiating the claim of the complainant and the present consumer complaint deserves to succeed.
5. Now coming to the quantum of amount, admittedly the complainant had raised claim of ₹14,815/- with the OPs, hence it is safe to hold that the OPs/ insurers are liable to pay the said amount to complainant alongwith interest and compensation etc.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under :-

1. to pay ₹14,815/- to the complainant alongwith interest @ 9% per annum (simple) from the date of repudiation of the claim i.e. 20.9.2023 onwards.
2. to pay ₹5,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹5,000/- to the complainant as costs of litigation.

5. This order be complied with by the OPs, jointly and severally, within a period of 45 days from the date of receipt of certified copy thereof, failing which the amounts mentioned at Sr.No.(i) & (ii) above shall carry penal interest @ 12% per annum (simple) from the date of expiry of said period of 45 days, instead of 9% [mentioned at Sr.No.(i)], till realisation, over and above payment of ligation expenses.
6. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

04/09/2024	Sd/- [Pawanjit Singh] President
	Sd/-
	[Surjeet Kaur] Member
	Sd/-
	[Suresh Kumar Sardana] Member