Case No.CC/410/2022

Date of Institution:-15.11.2022

Order Reserved on :- 04.12.2023

           Date of Order :-07.03.2024      

IN THE MATTER OF:

Mr. Kranti

House No. 267, Kakrola Village,

New Delhi – 110078.

          …..Complainant

VERSUS

Star Health and Allied Insurance Company Ltd.

1^st Floor, SCO-4, Huda Market,

Sector-14, Old Delhi Road,

Near Payal Cinema,

Gurgaon – 122001.

..…Opposite Party

O R D E R

R. C. YADAV , MEMBER

1. The present complaint has been filed under section 12 & 35 of Consumer Protection Act, 1986 (in short CP Act) against Opposite Party (in short OP) alleging deficiency of service.
2. Briefly stated the facts of the case are that the complainant  had taken an on line health insurance policy bearing no. P/161117/01/2021/009834 on 07.11.2020 from OP. It is further submitted that said policy was from 07.11.2020 to 06.11.2021 for the sum insured of Rs.3,00,000/- (Rupees Three Lacs only).  Copy of insurance policy is annexed with the complaint.
3. It is submitted that the complainant got admitted in the Parth Hospital for his treatment on 19.11.2021 and remained hospitalized till 23.11.2021. Rs.48,491/- (Rupees Forty Eight Thousand Four Hundred Ninety One only) was paid by the complainant. Copy of bill and medical treatment documents are annexed with the complaint.
4. It is further submitted that thereafter complainant claimed the aforesaid bill amount before the OP but the same was rejected Claim No. CIR/2021/161117/223273 by the OP on 21.04.2021 with reason mentioned as under:

1. The hospital registration got expired on 31.03.2019.  Thus the hospital in which the insured patient is said to have taken treatment was not registered during the above period of hospitalization.
2. In the registration certificate for the hospital, 20 beds are mentioned but there only 4 beds in general wards and 4 beds in the Pvt. or Semi Pvt Room.
3. Not a single doctor nor a patient was available in the hospital at the time of verification.
4. The ICPs including the medicine and vital chart are written in stereotyped handwritten.

5. It is submitted that the complainant sent a legal notice on 08.05.2021 to the insurance company but no response from the insurance company.
6. The complainant had claimed a real genuine bill Rs.48,491/- but the OP has rejected the claim.
7. In view of the above facts and circumstances, the complainant has been left with no option but to approach this Court. Hence, this present complaint.
8. The Complainant has requested OP to refund his paid amount Rs. 48,491/- (Rupees Forty Eight Thousand Four Hundred Ninety One only)  but in vain. The complainant has prayed to refund Rs.48,491/- with interest @ 18% alongwith cost of the case and litigation charges.
9. Notice of complaint was served to OP. OP did not appear to attend the proceedings and proceeded Ex-parte vide order dated 28.03.2023.
10. The Complainant has filed his affidavit in Ex-Parte evidence alongwith written arguments in support of his case.
11. We have gone through material on record carefully and thoroughly.
12. It is the case of complainant that complainant had taken an online health insurance policy bearing no.P/161117/01/2021/009834 on 07.11.2020 from OP.  The said policy from 07.11.2020 to 06.11.2021 for the sum insured of Rs.3,00,000/-.
13. The complainant got admitted in Parth Hospital on 19.11.2021 and hospitalized till 23.11.2021. The complainant has paid Rs.48,491/- to the hospital for his treatment. The complainant has claimed aforesaid bill from OP but the OP has rejected claim no. CIR/2021/161117/223273 dated 21.04.2021with reason that hospital registration got expired on 31.03.2019. Thus, hospital in which the insured patient is said to have taken treatment was not registered during the above period of hospitalization.  The OP has filed the evidence that the DG Health Services has issued the order in which the registration of hospital was extended upto 31.03.2021. The OP has rejected the claim vide letter dated 21.04.2021.
14. It is the case of complainant that he has paid Rs.3941/- to the OP as per the terms and conditions. It is the case of the complainant that he has paid Rs.48,491/- in the hospital and the same has not been refunded by the OP/ Insurance company.  The case of complainant does not suffer from any factual or legal defect. The allegations made by the complainant have gone unchallenged, uncontested and as such whatever has been placed on record is believed.  It is clear that despite purchase of insurance policy from OP, the OP has not paid the amount to the complainant and this act clearly constitutes ‘deficiency’ in service, monopolistic and unfair trade practice on the part of OP.
15. Accordingly, we allow the complaint and direct the OP to refund Rs.48,491/- (Rupees Forty Eight Thousand Four Hundred Ninety One) with interest @ 6% p.a. from the date of deposit of money alongwith Rs.10,000/- (Rupees Ten Thousand) as lumpsum for mental agony and litigation charges within 30 days from the date of receipt of the orders failing which OP shall be liable to pay entire amount with interest @ 9% p.a. till realization.

• Copy of the order be given/sent to the parties as per rule.
• The file be consigned to Record Room.
• Announce in the open Court on 07.03.2024 at 3.30 PM.