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

 

Complaint Case No : RBT/CC/2018/61

Date of Institution : 25.01.2018/29.11.2021

Date of Decision : 07.06.2022

Raj Kumar s/o Sh. Janak Raj r/o Near Krishna Cinema, Chatiwind Gate, Amritsar.   

…Complainant

Versus

1. HDFC Ergo General Insurance Co. Limited, Dhab Wasti Ram, Near Fire Brigade Office, Majith Mandi, Amritsar through its Branch Manager.

2. HDFC Ergo General Insurance Co. Limited, registered office at 1st Floor, 165-166, Back Bay, Reclamation HT Parekh Marg, Church Gate, Mumbai through its Authorized Signatory. 

…Opposite Parties

Complaint U/S 11 and 12 of The Consumer Protection Act

Present: Ms. Harsimrandeep Kaur Adv counsel for complainant

Sh. RP Singh Adv counsel for opposite parties.  

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 Raj Kumar filed the present complaint under Section 11 and 12 of the Consumer Protection Act against HDFC Ergo General Insurance Company Limited, Amritsar and another. (in short the opposite parties). 

2. The facts leading to the present complaint as stated by the complainant are that the complainant obtained insured policy No. 2952200972231101-2825 HDFC Ergo ID ER160291398001E and said policy was valid when complainant got done his operation. The complainant was admitted in the hospital on 18.3.2017 in Dr. Om Parkash Eye Institute Private Limited and after operation of catarict right eye the complainant was discharged on 18.3.2017 and he paid a sum of Rs. 28,000/- to the hospital vide bill dated 10.4.2017. The complainant duly informed the opposite party No. 1 and also submitted a claim form on 15.4.2017 but they did not pay any heed on the claim of the complainant. The opposite party No. 1 demanded certain inquiries and complainant fulfilled all inquiries and submitted requisite file as claimed by the opposite party No. 1 but the opposite party No. 1 did not pay any claim to the complainant. Hence the present complaint is filed seeking the following reliefs.-

1) The opposite parties may be directed to pay the claim amount of Rs. 28,000/- alongwith interest at the rate of 18% from the date of submission till realization. 

2) To pay Rs. 50,000/- on account of compensation for mental agony and harassment. 

3) To pay Rs. 10,000/- as costs of the litigation.

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

3. Upon notice of this complaint, the opposite parties filed written reply taking preliminary objections on the grounds that the complaint of the complainant is liable to be dismissed on the ground of claim being premature. The claim of the complainant was closed by the answering opposite party on the ground of non submissions of requisite documents as sought by the answering opposite party and in absence of requisite documents the answering opposite party was not able to decide the claim on merits and same was closed nor repudiated. The complainant was insured under the Health Suraksha Policy bearing No. 2952200972231101000 valid from 28.1.2017 to 27.1.2019 covering risk as mentioned in the policy schedule subject to terms and conditions of the insurance policy. The answering opposite party received a reimbursement claim alongwith documents on 21.4.2017 and as on 18.3.2017 the complainant was operated at Dr. Om Parkash Eye Institute Private Limited regarding cataract in right eye. After perusing the medical documents it was found that the patient had history of Hypertension and Diabetes so the answering opposite party requested the complainant to provide some documents but complainant has failed to provide the documents mentioned in the said letter. The opposite party again vide letters dated 26.5.2017, 14.6.2017 and 29.6.2017 requested to submit the requisite documents but complainant failed to provide the said documents. So the opposite parties closed the claim of the complainant vide letter dated 29.7.2017. There is no deficiency in service on the part of the opposite parties. The complainant has no locus standi to file the present complaint and this Commission has no jurisdiction to try the present complaint. 

4. On merits, it is submitted that the claim of the complainant was closed due to non submission of requisite documents as sought by the answering opposite parties so the claim was closed vide letter dated 29.7.2017. Lastly, the opposite parties prayed for the dismissal of the present complaint.  

5. The complainant tendered in evidence his own affidavit Ex.C-1, copy of certificate issued by Om Parkash Eye Hospital Ex.C-2, copy of discharge summary Ex.C-3, copy of claim form part A Ex.C-4, copy of claim form part B Ex.C-5, copy of check list Ex.C-6, copy of second reminder Ex.C-7 and closed the evidence. 

6. To rebut the case of the complainant the opposite parties tendered in evidence affidavit of Pankaj Kumar Ex.OP-1, copy of claim form Ex.OP-2, copy of letter dated 14.1.2017 Ex.OP-3, copy of letter dated 29.6.2017 Ex.OP-4, copy of letter dated 14.7.2017 Ex.OP-5, copy of letter dated 29.7.2017 Ex.OP-6, copy of discharge summary Ex.OP-7, copy of policy Ex.OP-8, copy of terms and conditions  Ex.OP-9, Record Ex.OP-W1/1 and closed the evidence. 

7. We have heard the learned counsel for the parties and gone through the record on the file. 

8. It is admitted fact between the parties that the complainant was insured with the opposite parties under the Health Suraksha Policy Ex.OP-8 valid from 28.1.2017 to 27.1.2019 for sum insured of Rs. 3,00,000/-. It is also not disputed that the complainant was operated at Dr. Om Prakash Eye Institute Private Limited regarding cataract in right eye on 18.3.2017 and discharged from the hospital on the same day vide discharge summary Ex.C-3. It is also admitted by the opposite parties that they received a reimbursement claim Ex.C-4 and Ex.C-5 alongwith documents on 21.4.2017. It is also admitted by the opposite parties that they have closed the claim of the complainant vide letter dated 29.7.2017 Ex.OP-6. 

9. The main dispute between the parties is that the opposite parties closed the claim of the complainant vide letter Ex.OP-6 on the ground that the complainant has not submitted the requisite documents with the opposite parties which were demanded by the opposite parties vide various letters Ex.OP-2 to Ex.OP-5. On the other hand the complainant deposed in his affidavit Ex.C-1 that the opposite party No. 1 demanded certain inquiries and complainant fulfilled all the inquiries and submitted requisite file as claimed by the opposite party No. 1 but even then the opposite party did not pay any claim to the complainant. Further, the complainant also filed these documents on the file in his evidence. 

10. Further, Dr. Beant Singh MS Eye Specialist Om Parkash Satyam Netrayala, Mall Road, Amritsar also mentioned in his statement recorded on 20.2.2019 that complainant was suffering from hypertension and diabetes before admitting in the hospital and he was taking medicines for the same and fact regarding hypertension and diabetes has been duly recorded in the case history of patient. Therefore, there is no concealment on the part of the complainant regarding these diseases and requisite inquiry of the opposite parties is also fulfilled from the statement of Dr. Beant Singh. Dr. Beant Singh further stated in his cross examination that at the time of operation blood pressure and sugar of the patient was under control and normal. They did the operation only when BP and sugar of the patient were under control. In our view the opposite parties must do the medical check up of the complainant before issuing the policy but now after taking premium and issuing policy to the complainant, the opposite parties cannot take these type of objections. 

11. Further, complainant also filed copy of certificate of Dr. Om Prakash Eye Institute Ex.C-2 in his evidence alongwith discharge summary Ex.C-3. He also filed copies of claim forms Ex.C-4 and Ex.C-5 in his evidence to prove that he has already submitted the claim form with opposite parties but they have not paid the claim to him. In this way, opposite parties are deficient in providing service to the complainant. 

12. In view of above discussion, present complaint is partly allowed and opposite parties are directed to pay Rs. 28,000/- to the complainant on account of insurance claim alongwith interest at the rate of 7% per annum from the date of filing of present complaint till actual realization. The opposite parties are further directed to pay Rs. 5,500/- as consolidated amount of compensation to the complainant for mental tension, harassment and litigation expenses. Compliance of the 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 Commission, Amritsar as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar. 

ANNOUNCED IN THE OPEN COMMISSION:

        7th Day of June 2022

 

            (Ashish Kumar Grover)

            President

 

              (Navdeep Kumar Garg)

Member