DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION FAZILKA.
Complaint No. RBT/CC/195/2023 – CC/291/2022
Date of Institution: 03.11.2022
Date of Decision : 16.09.2024
Sandeep Singh aged about 27 years son of Mahinder Singh, Resident of Dibbi Pura, Bahmaniwala, Fazilka, Tehsil and District Fazilka, Pin-152024, Mobile no.99146-11279.
………..Complainant
Versus
- Niva Bupa Health Insurance, through its Manager Gokal, having branch office at near DSP Office, Jalalabad, Tehsil Jalalabad, District Fazilka, Pin-152123.
- Niva Bupa Health Insurance, having office at 4th Floor, Viman Nagar, Finserv Office, Pune-Ahmed Nagar Road, Pune-411014, Maharashtra, through its authorized signatory. ......Opposite Parties
Complaint under section 35 of Consumer Protection Act, 2019.
RBT/CC/195/2023
Quorum: Sh.Vishal Arora, President.
Sh.Raghbir Singh Sukhija, Member.
Smt.Tajinder Kaur, Member.
Present: Sh.Sunil Kumar, Advocate, counsel for complainant.
Sh.Y.R.Puri, Advocate, counsel for opposite parties.
ORDER
(Vishal Arora, President):
Complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against opposite parties for seeking directions to pay insured amount of Rs.1,00,000/- along with interest @ 12% per annum and also reimburse the medical bills of the complainant besides Rs.3,00,000/- as compensation for mental agony/harassment along with litigation expenses to the tune of Rs.22,000/-.
2. Briefly stated, the case of complainant is that the officials of opposite parties approached the complainant to get an Insurance policy of the opposite parties and on their assurance and advice, complainant purchased one policy bearing No.50202600202100 of the opposite parties vide cover inception dated 09.03.2022 which is valid up to 08.03.2023 for an amount of Rs.1 lac under the terms and conditions of the policy. As per the cover note of
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the Insurance policy, number of treatments are covered up to sum insured in which surgical operations including pre and post operative care are covered. On 12.04.2022, the complainant met with an accident and due to that accident from bike sleeping, the complainant suffered major problem in his right knee. The family members of the complainant immediately admitted the complainant in Wadhawa Ortho Hospital at Muktsar which is specialized in Ortho Problem and is near from the house of the complainant. The doctors of the Hospital diagnosed a major problem in the right knee of the complainant and advised a surgery of knee through the procedure of PCL (Posterior Cruciate Ligament). As per said advice, the complainant gave his consent for surgical treatment and on 15.04.2022, the concerned doctor performed the surgery. The family members and relatives of the complainant informed the manager of the opposite party No.1 through oral submission who gave assurance that the company would pay all expenses spent on the treatment of complainant and also asked to lodge claim for reimbursement with all the medical bills after discharge. The complainant was discharged on 16.04.2022 and after 12-15 days, uncle of the complainant met the manager of the
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opposite party no.1, submitted all medical bills along with discharge summary and completed all the formalities. But, till date the opposite parties are lingering the matter on one pretext to other with lame excuses. The complainant spent approximately Rs.1,00,000/- on his treatment i.e. hospitalization charges and pharmacy bills. As per the terms and conditions of the policy, the opposite parties are bound to reimburse the medical bills of the complainant, but till date they have not reimbursed the same. Pleading deficiency in service and unfair trade practice on the part of opposite parties, the complainant has prayed for acceptance of the present complaint.
3. The counsel for complainant was heard with regard to admission of the complaint and vide order dated 25.11.2022, the complaint was admitted and notice was ordered to be issued to the opposite parties.
4. Upon notice, the opposite parties have appeared and filed written statement raising certain preliminary objections interalia to the effect that on receipt of the present complaint, the opposite parties searched the complaint documents but could not find any claim amounting to
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approximately Rs.1 lac from Wadhwa Ortho Hospital, Muktsar. The complainant has also not attached any repudiation or settlement letter. The insurance company has not been provided with any claim documents or any detail of rejection of claim. The complainant has to furnish the original bills/receipts of Rs.1 lac along with documents related to hospitalization for the company to check its veracity. Lastly, a prayer has been made for direction to complainant to lodge claim with the opposite parties. All other allegations leveled by complainant have been denied being wrong and incorrect. It has been reiterated that there is no deficiency in service or unfair trade practice on the part of opposite parties. The allegations with regard to relief sought too were refuted with a prayer that complaint deserves to be dismissed with cost.
5. The complainant along with the present complaint has placed on record affidavit Ex.C-1, Copies of, certificate of insurance Ex.C-2, bills Ex.C-3 to Ex.C-10 and discharge summary Ex.C-11. Opposite parties have placed on record Copies of, letter of authorization Ex.OP’s/1, Certificate of
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insurance Ex.OP’s/2, Policy terms and conditions Ex.OP’s/3 to Ex.OP’s/4, letter dated 10.09.2021 Ex.OP’s/5, Policy document Ex. OP’s/6 and affidavit of Dev Bhattacharya Ex.OP’s/7.
6. We have heard the Ld. counsel for the parties and have also very carefully gone through the record. The Learned counsel for complainant and opposite parties have argued on the same lines as per their respective pleadings.
7. The main plea put forward and argued by the Ld. counsel for the opposite parties is that on receipt of the present complaint, the opposite parties searched the complaint documents but could not find any claim amounting to approximately Rs.1 lac from Wadhwa Ortho Hospital, Muktsar. The complainant has also not attached any repudiation or settlement letter. The insurance company has not been provided with any claim documents or any detail of rejection of claim. The complainant has to furnish the original bills/receipts of Rs.1 lac along with documents related to hospitalization for the company to check its veracity. Lastly, a prayer has been made for direction to complainant to lodge claim with the opposite parties.
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Perusal of the file reveals that the complainant has not placed on record any documentary evidence to prove that any claim along with requisite documents has been lodged by the complainant with the opposite parties.
8. In view of what has been discussed above, the present complaint stands disposed off being premature with a direction to the complainant to lodge the claim with the opposite parties along with the requisite documents. And on receipt thereof, the opposite parties will decide the admissibility of the claim of the complainant within a period of 45 days including demand of additional documents, if any. In case, the admissibility of the claim is not decided within the stipulated period of 45 days, then opposite parties shall be liable to pay to the complainant Rs.300/- per day for the period of delay. If the complainant is dissatisfied with the decision taken by the Insurance company, the complainant shall be at liberty to file a fresh complaint on the same cause of action. The present complaint is disposed off accordingly.
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Copies of order be supplied to the parties free of costs under the rules. File be consigned to the record room.
ANNOUNCED IN THE OPEN COMMISSION:
16th Day of September, 2024
(Vishal Arora)
President
(Raghbir Singh Sukhija)
Member
(TajinderKaur )
Member
