Haryana

Bhiwani

CC/362/2019

Baljeet - Complainant(s)

Versus

Aditya Birla - Opp.Party(s)

Anil Dinodia

25 Jul 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BHIWANI.

 

                                                            Consumer Complaint No. :  362 of 2019

                                                        Date of Institution           : 13.06.2019

                                                                  Date of order                  : 25.07.2024

 

Baljeet son of Sh. Bir Singh R/o village Dharanwas, Tehsil Tosham, District Bhiwani.

  

           ……Complainant.

 

Versus

 

1.       Aditya Birla Health Insurance Company Ltd., R-Tek Park, 10^th Floor, Nirion Compound, Western Express Highway, Goregaon, East Mumbai-400063 through its Branch Manager.

 

2.       HDFC Bank Ltd., Jau, Tehsil and District Bhiwani through its Branch Manager.               

 

…… Opposite Parties.

 

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

 

BEFORE:       Mrs. Saroj Bala Bohra, Presiding Member.

  Ms. Shashi Kiran Panwar, Member.

 

Present:-       Sh. Anil Dinodia, Advocate for complainant.

                    Sh. R.K. Verma, Advocate for OP No.1.

                    Sh. Ravinder Kumar Punia, Advocate for OP No.2.

 

ORDER:

 

Saroj Bala Bohra, Presiding Member:

 

1.                 In brief, facts of this case are that complainant taken a health insurance policy from OP No.1 through OP No.2 on 06.06.2018 for a period of one year. It is stated that in the month of October 2018, complainant suffered some disease and taken treatment from Sarvodaya Multispecialty and Cancer Hospital, Hisar at the instanced of OP No.1. Complainant remained admitted in the hospital from 18.10.2018 to 22.10.2018 and incurred Rs.21,129/-. So, a claim submitting all necessary documents was lodged with OP No.1 but the claim was not paid despite submitting requisitioned documents and issuing of legal notice on 30.03.2019. Hence, the present has been preferred by complainant alleging deficiency in service on the part of OP resulting into monetary loss besides mental and physical harassment. In the end, prayer has been made to direct the OP to pay Rs.21,129/- besides a sum of Rs.50,000/- as compensation for harassment and Rs.5500/- towards litigation expenses. Any other relief to which this Commission deems fit has also been sought.

2.                 Upon notice, OPs appeared through their respective counsel. OP No.1 filed written statement raising preliminary objections qua maintainability of complaint, jurisdiction, deficiency in service, cause of action and suppression of material facts. On merits, it is submitted that policy bearing No.11-18-0010271-00 was issued to complainant. It is submitted that on receiving of reimbursement claim, it found that there were certain pending documents to process the claim so vide e-mails dated 14.12.2018, 24.12.2018, 03.01.2019 and 13.01.2019 were sent to complainant but he failed to submit the original hospital bills, investigation report of diagnosis and discharge card. As such, delay and negligence is on the part of complainant and thus the claim of complainant was on hold. In the end, denied for any deficiency in service on their part and prayed for dismissal of complaint

3.                 OP No.2 submitted written statement admitting that the policy was issued to the complainant through OP bank. Rest of the contents of complaint have been denied and prayed for dismissal of the complaint with exemplary costs.  

4.                 In evidence of complainant, his affidavit Ex.CW1/A alongwith documents Ex. C-1 to Ex. C-22 were tendered and then closed the evidence on 10.04.2023.

5.                 In evidence of OP No.1, affidavit of Mr.Vikram Jain, AVP, Legal as Ex. RW1/A alongwith documents Annexure R-1 to Annexure R-6 were filed and then closed the evidence on 05.06.2024.

6.                 On behalf of OP No.2, affidavit Ex. RW2/A of Mr. Naveen Kumar, Branch Manager alongwith document Ex. R2/1 were filed and closed the evidence on 05.06.2024.

7.                 We have heard learned counsels for the parties and perused the record carefully.

8.                 It is not in dispute that complainant was covered under the policy during the period of treatment. As per pleadings of the OP insurance company, claim has been denied to complainant for non-submission of documents necessary for processing of claim viz. original hospital bills, investigation report of diagnosis and discharge card. On the other side, complainant has alleged that all the documents were submitted with the OP insurance company and copies thereof have been placed on record.

9.                 After hearing learned counsels for the parties and going through the record, it is evident that from the medical bills of the concerned hospital Ex. C-11 to Ex. Ex. C-21, complainant has incurred a sum of Rs.21029/-.  However, discharge slip has not been placed on record. In such a situation, we think that ends of justice would be met if the complaint is allowed subject to submission of discharge certificate of the concerned hospital by complainant for the relevant period. As such, the complaint is partly allowed and the OP No.1 insurance company is directed to comply with the following directions within 40 days from the date of order:-

(i)       To pay a sum of Rs.21,029/- (Rs. Twenty one thousand twenty nine) to the complainant so incurred by him on the treatment subject to submission of discharge certificate within 10 days of the receipt of certified copy of this order.

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

                    In case of non-compliance, all the awarded amounts shall attract simple interest @ 12% per annum for the period of default. 

                    Further, the complainant shall be entitled to the execution petition under section 71 of Consumer Protection Act, 2019 and in that eventuality, the opposite party no.1 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.  Certified 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: 25.07.2024