DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (CENTRAL)
ISBT KASHMERE GATE DELHI
CC/143/2016
Pawan Kumar Jindal
3254/236, Chander Nagar,
Tri Nagar, Delhi-110035.…..COMPLAINANT
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BLK Hospital,
Pusa Road, Karol Bagh,
New Delhi-110055.
The Oriental Insurance Company Ltd.
7678 Singh Sabha Road,
Near Amba Cinema Road,
New Delhi-110007.…..OPPOSITE PARTIES
Quorum: Ms. Rekha Rani, President
Ms. Manju Bala Sharma, Member
Dr. R.C. Meena, Member
ORDER
Ms. Rekha Rani, President
- Instant complaint has been filed by Sh. Pawan Kumar Jindal (in short the complainant) under Section 12 of the Consumer Protection Act 1986 (in short the Act) as amended up to date inter-alia pleading therein that he had undergone for surgery for treatment of LT Ureteric Calculus at BLK Hospital (in short OP1) for which a bill of Rs.56,919.84/- was raised which was reimbursable under the medical insurance policy taken by him from Oriental Insurance Company Ltd. (in short OP2). OP2 has paid Rs. 51,905/- on account of cashless facility and Rs. 5,522/-was repudiated by OP2 unjustifiably which is claimed by him along with Rs. 90,000/- as compensation for causing mental agony.
- On receipt of notice of the instant complaint, OP2 appeared and filed its reply wherein it is pleaded that the complainant incurred expenditure of Rs. 53,125 out of which Rs. 47,603/- was paid to the hospital on behalf of the complainant by OP2 and a sum of Rs. 5,522/- was not paid as the same was not payable.
- We have heard the complainant, Sh. Sharad Panwar, AR of OP1 and Sh. Kapil Chawla, counsel for OP2. Parties have adduced evidence by way of affidavits. They have also filed written arguments.
- Learned counsel for OP2 has submitted that since the amount of Rs. 5,522/- was spent on non-payable items, the same was not approved to be paid by OP.
- When we asked learned counsel for OP2 to satisfy us how and why the said amount is not payable he was not able to satisfy us. OP has not explained as to why the said articles are non payable as the same were used for surgical treatment.
OP cannot restrict its liability arbitrarily.Before State Consumer Disputes Redressal Commission, Maharashtra, Mumbai in First Appeal No. A/14/655 titled National Insurance Co. Ltd. vs. Mr. Jimmy Dali Bharucha, the Complainant No.1 had drawn a Mediclaim for Family policy and paid premium to Opponent No.1 (the Appellant).During subsistence of the policy, the Complainant No.1, on 15/05/2011 was diagnosed for coronary heart disease and was hospitalized for angioplasty during 15/08/2011 to 18/08/2011 and spent for over Rs. 2,25,000/- to recover out of illness.Opposite Party No.1 filed written version to accept the liability but, to the extent of 50% amount, as per policy document. State Consumer Disputes Redressal Commission, Maharashtra, Mumbai, vide its order dated 06.05.2015 observed that:
“Upon considering rival contentions and perusing the record we concur with the finding of the fact recorded by trial forum for the reason that, Note (a), which reads as, “Company’s liability would arise if the treatment or disease or injury contracted / suffered is incepted during the policy period. Total expenses incurred for any one illness is limited to 50% of Sum Insured per family. Company’s liability in respect of all claims admitted during the period of insurance shall not exceed the Sum Insured mentioned in the Schedule.”, appears to be unilateral in nature and non-executable in character otherwise, there will be no meaning for mentioning insured sum of Rs.2,00,000/- or more when the Opponent No.1/Insurance Company recovers the premium for the said amount.”
Accordingly, complainant is entitled to payment of Rs. 5,522/- along with Rs. 5,000/- as litigation expenses.Copy of this order be sent to the parties as statutorily required. File be consigned to record room.
Announced on this of 2019.
