DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, CAMP COURT AT AMRITSAR, PUNJAB.

 

Complaint Case No : RBT/CC/2018/42

Date of Institution : 17.01.2018/29.11.2021

Date of Decision : 16.08.2022

Gunjan Seth D/o Kamal Seth resident of D-3/1790, Gali No. 11, Ram Nagar Colony, Amritsar.      …Complainant

Versus

HDFC ERGO General Insurance Company Limited (HDFC), 1st Floor, 165-166, Backbay Reclamation, H.T. Parekh Marg, Church Gate, Mumbai through its Managing Director/Chairman. 

…Opposite Party

Complaint U/S 12 and 14 of The Consumer Protection Act

Present: Sh. Vinay Khera Adv counsel for complainant.

Sh. RP Singh Adv counsel for the opposite party. 

Quorum.-

1. Sh. Ashish Kumar Grover : President

2. Sh. Navdeep Kumar Garg : Member

(ORDER BY ASHISH KUMAR GROVER PRESIDENT):

    The present complaint has been received by transfer from District Consumer Commission, Amritsar in compliance of the order dated 26.11.2021 of the Hon'ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh. The complainant filed the present complaint under Section 12 and 14 of the Consumer Protection Act against HDFC Ergo General Insurance Company Limited, Mumbai. (in short the opposite party). 

2. The facts leading to the present complaint as stated by the complainant are that the complainant get insured a Health Policy namely Health Suraksha Insurance Policy from the opposite party against premium of Rs. 4,095/- having policy No. 2828201818406700000 for the period from 20.6.2017 to 19.6.2018 for sum insured of Rs. 3 lacs. The complainant received the policy card from the opposite party. 

3. It is further alleged that later on complainant met with an accident and received multiple injuries on 8.7.2017 as she fell down from the stairs and complainant was admitted in Akashdeep Hospital Amritsar on 8.7.2017 and she went through major operation of spinal cord. Complainant was discharged on 24.7.2017 from the said hospital but she is still under the medical treatment and not fully recovered from the injury. At the time of admitting in the hospital the complainant conveyed the opposite party through her parents as well as through hospital authorities on 8.7.2017 and investigation was also done by the opposite party. The complainant has paid amount of Rs. 1,56,835/- to the said hospital for treatment and further bearing the same in the shape of taking medicines, regular check up as well as for physiotherapy. It is further alleged that the opposite party has failed to pay any money till date to the complainant without any reason and later on refused to pay the same which amounts to deficiency in service and unfair trade practice. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite party may be directed to pay a sum of Rs. 3 lacs after getting discharged from the hospital the complainant till date has spent more than Rs. 3 lacs on her treatment and further bearing the same. 

2) To pay interest at the rate of 18% per annum for delayed period from July 2017 till date of realization.

3) To pay Rs. 1,00,000/- on account of compensation for mental agony and harassment. 

4) To pay Rs. 10,000/- as litigation expenses.

5) Any other relief to which the complainant is found entitled. 

4. Upon notice of this complaint, the opposite party filed written statement taking preliminary objections that after receiving the claim intimation from the complainant letters dated 29.12.2017, 13.1.2018 and 28.1.2018 were sent to the complainant and sought documents and clarification mentioned in the letters, but neither the documents nor information was provided so vide letter dated 12.2.2018 the claim was considered as closed and due intimation of the same was sent to the complainant which fact has been concealed by the complainant and until and unless the documents and information is not provided the claim cannot be decided. The complainant has no cause of action and locus standi to file the present complaint. 

5. On merits, the insurance of the complainant is admitted. The claim of the complainant was closed in absence of documents and clarification. Further, all the submissions mentioned on merits are the same as submitted in the preliminary objections so there is no need to repeat the same. However, the opposite party alleged that there is no deficiency in service and unfair trade practice on the part of the opposite party. Lastly, the opposite party prayed for the dismissal of the present complaint.

6. To prover her case the complainant tendered in evidence her own affidavit Ex.C-1, copy of insurance policy Ex.C-2, copy of acknowledgment Ex.C-3, copy of insurance card Ex.C-4, copy of medical record Ex.C-5, copy of bills Ex.C-6 to Ex.C-70, postal receipt dated 9.9.2017 Ex.C-71, postal receipt dated 26.7.2017 Ex.C-72 and closed the evidence. 

7. To rebut the case of the complainant the opposite party tendered in evidence affidavit of Pankaj Kumar Manager Ex.OP-1/A, copy of letter dated 12.2.2018 Ex.OP-1, copy of letter dated 29.12.2017  Ex.OP-2, copy of letter dated 28.1.2018 Ex.OP-3 and closed the evidence.   

8. We have heard the learned counsel for the parties and gone through the record on the file. Written arguments also filed by both the parties. 

9. It is not disputed between the parties that the complainant purchased the Health Suraksha Insurance Policy Ex.C-2 from the opposite party who issued insurance card Ex.C-4 to the complainant. It is also not disputed that the complainant got the treatment within the validity of the insurance policy. 

10. Learned counsel for the complainant argued that complainant met with an accident and received multiple injuries on 8.7.2017 as she fell down from the stairs and complainant was admitted in Akashdeep Hospital Amritsar on 8.7.2017 and was discharged on 24.7.2017 but she is still under the medical treatment and not fully recovered from the injury. He further argued that complainant conveyed the opposite party through her parents as well as through hospital authorities on 8.7.2017 and investigation was also done by the opposite party and she paid amount of Rs. 1,56,835/- to the said hospital for treatment and further bearing the same in the shape of taking medicines, regular check up as well as for physiotherapy and till date spent about Rs. 3 lacs for her treatment but opposite party has failed to pay any money till date without any reason and later on refused to pay the same which amounts to deficiency in service on their part. 

11. On the other hand the learned counsel for the opposite party argued that after receiving the claim intimation from the complainant letters dated 29.12.2017 Ex.OP-2, 13.1.2018 and 28.1.2018 Ex.OP-3 were sent to the complainant and sought documents and clarification mentioned in the letters, but neither the documents nor information was provided so vide letter dated 12.2.2018 Ex.OP-1 the claim was considered as closed and due intimation of the same was sent to the complainant. He further argued that the claim of the complainant was closed in absence of documents and clarification.

12. We have perused the copy of letter dated 12.2.2018 Ex.OP-1 in which the opposite party referred their earlier letters vide which they  demanded some documents and clarifications from the complainant. It is further mentioned in this letter Ex.OP-1 that as they have not received the documents so due to non submission of documents the opposite party consider the claim as closed. The complainant filed all her medical record Ex.C-5 on the file so there is no hitch to her to provide the same to the opposite party. Further, the complainant also filed copies of bills Ex.C-6 to Ex.C-70. The opposite party can also take the copies of documents from the file and settle the claim of the complainant but the opposite party has not taken any steps to settle the claim of the complainant except to write letters to the complainant which proves that the opposite party is not interested to pay the claim of the complainant. This act of the opposite party is clear cut deficiency in service and unfair trade practice on their part. 

13. The complainant filed copies of bills Ex.C-6 to Ex.C-69 and the amount of these bills comes to Rs. 1,09,685/-. Except these bills the complainant has not filed any other bill so, she is entitled to get an  amount of Rs. 1,09,685/-. 

14. In view of the above discussion, present complaint is partly allowed and opposite party is directed to pay the amount of Rs. 1,09,685/- to the complainant on account of insurance claim alongwith interest at the rate of 6% per annum from the date of filing of present complaint till actual realization. The opposite parties are also directed to pay Rs. 10,000/- to the complainant as compensation for mental tension and harassment and Rs. 5,500/- as costs and litigation expenses. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order will be supplied to the parties by the District Consumer Disputes Redressal Commission, Amritsar as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar. 

ANNOUNCED IN THE OPEN COMMISSION:

        16th Day of August 2022

 

 

            (Ashish Kumar Grover)

            President

              

(Navdeep Kumar Garg)

Member