Haryana

StateCommission

A/684/2015

HDFC ERGO GEN.INSURANCE CO. - Complainant(s)

Versus

ASHOK KUMAR GOYAL - Opp.Party(s)

SANDEEP SURI

21 Nov 2016

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal No  : 684 of 2015

Date of Institution: 19.08.2015

Date of Decision : 21.11.2016

 

M/s HDFC ERGO General Insurance Company Limited, service is effected through its branch office: Shubham Tower, Neelam Bata Road, NIT Faridabad, through its  Branch manager.

                                      Appellant-Opposite party No.1

 Versus

 

1.      Ashok Kumar Goel s/o Sh. Mani Ram Goyal resident of H. No. 1732, Sector-7, Urban Estate, Karnal.

Respondent-Complainant

2.      Family Health Plan (TPA) Ltd., Plot No. 8, 2^nd Floor, Retail Business Centre, Nangal Raya, Opp Janak Puri, D Block, Delhi.                                    

                                      Respondent- Opposite Party No.2  

 

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Shri B.M. Bedi, Judicial Member.

                             Shri Diwan Singh Chauhan, Member   

 

Argued by:          Sh. Puneet Tuli, Advocate for the appellant.

Sh. Jagdeep Rana, Advocate for the respondent No.1.

(Service of Respondent No.2 dispensed with vide order dated 2015)

 

                                                   O R D E R

 

B.M. BEDI, JUDICIAL MEMBER

 

          M/s HDFC ERGO General Insurance Company Limited-opposite party No.1 is in appeal against the order dated 21.05.2014 passed by the District Consumer Disputes Redressal Forum, Karnal (in short, ‘District Forum’).

2.      Ashok Kumar Goyal-complainant filed complaint with allegation that he purchased a health insurance policy from HDFC ERGO-opposite party No.1 for hospitalization and treatment for Rs.1,00,000/- towards hospitalization and Rs.2000/- per day towards hospital cash. The complainant suffered chest pain on 13.07.2010 and was initially admitted to Parveen Hospital, Karnal. Thereafter he wasshifted to Jai Pur Golden Hospital, Rohini, Delhi where he received treatment from 14.07.2010 to 18.07.2010. Complainant spent a sum of Rs.1,61,977/- on his treatment.  The amount not being paid to the complainant, the complainant filed complaint under Section 12 of the Consumer Protection Act, 1986 claiming Rs.1,00,000/- for treatment besides compensation.

3.      The opposite party No.1 contested the complaint stating that the complainant had a past history of hypertension and diabetes and though initially opposite party No.2 approved cashless service, however, on verifications of the records from Parveen Hospital, Karnal, complainant having past history of DM, HTN, CAD, the cashless facilities were withdrawn. It prayed for dismissal of complaint.

4.      District Forum after hearing both the parties allowed the complaint and directed opposite party No.1 to pay a sum of Rs.1,61,977/- alongwith interest @ 9% per annum from the date of filing of complaint till realization besides Rs.20,000/- for harassment and Rs.2200/- towards litigation expenses to the complainant.

5.      Aggrieved of the order of the District Forum, the opposite party No.1 has come up in appeal. 

6.      We heard learned counsel for the parties and perused the file.

7.      Though learned counsel for appellant submitted that the complainant had history of DM, HTN, CAD, however, there is no evidence or documents in support of the said contention.  The second contention was that despite the insurance cover being issued to the extent of one lac, District Forum directed compensation of Rs.1,61,977/- to the complainant. We have seen the complaint. The complainant himself has specifically stated in the complaint that the health insurance cover was to the extent of Rs.1,00,000/- and claimed the said amount.  However, District Forum awarded the compensation beyond the scope of complaint itself, which the District Forum could not have done.  Thus the order is modified to the extent that the complainant was entitled to compensation of Rs.1,00,000/- alongwith interest at the rate of 9% per annum however, rest of the order is maintained. With this modification the appeal is disposed of.

8.      The statutory amount of Rs. 25000/- deposited at the time of filing the appeal be refunded to the complainant against proper receipt and identification in accordance with rules.

 

Announced 21.11.2016

(Diwan Singh Chauhan) Member

(B.M. Bedi) Judicial Member

(Nawab Singh) President