Delhi

New Delhi

CC/97/2010

Sapan Garg - Complainant(s)

Versus

M/S. The New India Assurance Company Ltd. - Opp.Party(s)

03 Feb 2020

ORDER

 

 

                      CONSUMER DISPUTES REDRESSAL FORUM-VI

                  (DISTT. NEW DELHI),

                  ‘M’ BLOCK, 1^STFLOOR, VIKAS BHAWAN, I.P.ESTATE,

                                               NEW DELHI-110001

 

               Case No.C.C.97/2010                                                                    Dated:

               In the matter of:

Sapan Garg,

R/o  B-8/15,16,

Sec.11, Rohini,  Delhi-110085.

                                                              ……..COMPLAINANT

VERSUS

1.    The New India Assurance Co. Ltd.

A-2/3, Lusa Tower,

Azadpur, Delhi-33.

 

Also at :

The New India Assurance Co. Ltd.

Regional Office:

Jeevan Bharti Building,

124, Connaught Circus,

 New Delhi-01.

 

2.    E- Meditek, TPA Solution Ltd.,

Corporate office 45,

Nathupur Road, DLF Ph.III,

Gurgaon(Haryana)-122002.

Opposite Parties.

 NIPUR CHANDNA, MEMBER

 

ORDER

       

The complainant has filed the present complaint against the OPs under section 12 of Consumer Protection Act, 1986.  The gist of the complaint is that the complainant is the  mediclaim policy holder of the OP Co. vide policy bearing No.320100/34/09/13/00001096 for the period from 19.7.2009 to 18.7.2010.  On 26.10.2009 , the wife of the  complainant was admitted in Ekansh Nursing Home for the treatment of pyrexia and discharged from the Hospital on 9.11.2009. On 28.10.2009, the complainant sent intimation letter  about the  hospitalization to OP-2 and also submitted his claim of Rs.1,12,226/- with OP-2.  On 4.1.2010, the complainant wrote a letter to both the OPs to settle his claim but none of the OPs replied to the letter nor has settled the claim.  Complainant, therefore, approached this Forum for redressal of his grievance.

2.     Complaint has been contested by OP-1.  In its written statement,    OP-1  has not disputed that complainant had taken policy referred above. OP-1 has stated that there is no deficiency in service on its part as alleged by the complainant.  It has been further stated that the claim lodged appeared to be manipulated and as such OP-2 appointed the Investigator.  The said investigator obtained the treatment record from the hospital, from the said documents, it was notice that the hospital had concealed the fact that the  complainant’s wife was having  34 weeks pregnancy and was  a known case of Lower Segment Caesarian Section( LSCS).  It is further stated that against the treatment given the hospital has not encashed the cheque given by the complainant, hence the malafide intention and collusion of the hospital is exposed from this aspect and as such the claim was rightly repudiated. And further prayed for  dismissal of present complaint.    

3.     Both the parties have filed their evidences by way of affidavit,

4.     We have heard argument advance at the Bar and have perused the record.

5.     It is argued on behalf of complainant that the OP had arbitrarily repudiated his claim, despite receiving the premium against the sum insured.

6.     It is argued on behalf of OP that the claim lodged appeared to be manipulated and as such OP-2 appointed the Investigator.  The said investigator obtained the treatment record from the hospital, from the documents, it was notice that the hospital had concealed the fact that the  complainant’s wife was having  34 weeks pregnancy and was  a known case of  LSCS.  It is further stated that against the treatment given the hospital has not encashed the cheque given by the complainant, hence the malafide intention and collusion of the hospital is exposed from this aspect and as such the claim was rightly repudiated.

7.     Some facts are not disputed by the parties such as the policy documents, treatment taken.  OP-1 Co. in its repudiation letter has not denied that the patient has taken the treatment of pyrexia   of unknown origin.  The OP-1 repudiated the claim on the ground that the hospital has concealed the fact of pregnancy but failed to establish the nexus between the pyrexia and pregnancy having any bearing on the claim.  OP-1 in its repudiation letter had also repudiated the present claim on the ground that the hospital authority purchased the policy for poor people and got them admitted in their hospital in super deluxe and claim reimbursement.  In support of this contention, OP-1 failed to establish that the complainant is a poor person and had purchased the policy from the hospital, whereas, the policy in question was taken from the agent Capital Insurance Broker Pvt. Ltd. Hence, we are of the view that the repudiation was arbitrary and on frivolous ground.  Non-settlement of the claim of the complainant by OP-1 amount to deficiency in services. Therefore, we hold OP-1 guilty of deficiency of service and direct it as under:-

1. Pay to the complainant a sum of Rs.1,12,226/- alongwith 9% interest from the date of filing of complaint i.e. 28/01/2010 till realization.

 

2. Pay to the complainant a sum of Rs. 20,000/- on account pain and mental agony suffered by him, which will also include the cost of litigation.

 

A copy of this order each be sent to both the parties free of cost by post. This final order be sent to server (www.confonet.nic.in ). File be consigned to Record Room.

Announced in open Forum on 03/02/2020

 

 

 

(ARUN KUMAR ARYA)

          PRESIDENT

(NIPUR CHANDNA)                                                  (H M VYAS)

       MEMBER                                                                MEMBER