Haryana

Karnal

CC/310/2018

Shishpal Singh - Complainant(s)

Versus

Cigna TTK Pro Health Insurance Company Limited - Opp.Party(s)

Abhishek Tanwar

28 Feb 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

                                                          Complaint No. 310 of 2018

                                                          Date of instt. 13.11.2018

                                                          Date of Decision 28.02.2019

 

Shishpal Singh aged about 34 years son of Shri Lal Singh resident of VPO Katlaheri Tehsil and District Karnal (Aadhaar no.373441309561)

 

                                                                    …….Complainant

                                        Versus

 

1. Cigna TTK Pro Health Insurance Co. Ltd. 32-B, 3^rd floor, Rajomder Nagar, Pusa Road, near Pillar no.122 of Metro Station, Karol Bagh, New Delhi-110005 through its Managing Director.

2. Park Hospital, CHD City, Sector-45, Bhaini Khurd, G.T. Road, Karnal through its Administrator.

 

                                                                    …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act. 

 

Before    Sh. Jaswant Singh……President. 

      Sh.Vineet Kaushik ………..Member

                Dr. Rekha Chaudhary…….Member

 

 Present:  Shri Abhishek Tanwar Advocate for complainant.

                   OPs exparte.

 

                   (Jaswant Singh President)

 

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that complainant purchased a mediclaim policy of an amount of Rs.10 lakhs from OP no.1, vide policy no.PROHLR980158135 valid from 22.09.2018 to 21.09.2019. The said policy is for entire family of the complainant which is consisting of his wife, son and daughter. On 22.10.2018 at about 4.00 p.m. the complainant suffered from high grade fever, cough with expectoration, severe headache, severe generalized weakness, nausea. His condition was critical and as such he was admitted in the Park Hospital where remained admitted uptill 27.10.2018.  OP no.2 gave the estimate of treatment of the complainant of Rs.47500/- to the OP no.1 and OP approved the claim of Rs.25,000/- and it was observed that the remaining amount of Rs.22,500/- would be paid by the complainant. But lateron OP no.1 repudiated the entire claim of the complainant with the observation that “we have received cashless request for LRTI with febrile illness, claimant covered under policy since 22.09.2018. As per policy condition v.2 any disease contracted and/or medical expenses incurred in respect of any pre-existing disease/illness by the insured/insured person during the first 30 days from the inception date of the policy will not be covered.”  Due to repudiation of the claim of the complainant even for an amount of Rs.25,000/- the OP no.2 charged full and final payment of Rs.43,247/- from the complainant. The repudiation of the claim of the complainant is illegal, null and void because the 30 days period of the policy was completed on 21.10.2018 and the complaint fell ill on 22.10.2018 and was admitted at 4.25 p.m. in the hospital which is evidence from the discharge summary. On receipt of repudiation letter complainant approached the OPs for making payment of the insured amount but OPs has been postponing the matter on one pretext or the other and lastly refused to pay the claim. In this way, there was deficiency in service on the part of the OPs, due to which complainant suffered mental pain and agony apart from financial loss.

2.             Notice of the complaint was given to OPs. None put into appearance on behalf of OPs despite service, therefore, exparte proceedings were initiated against them, vide order dated 27.12.2018.

3.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C12 and closed the evidence on 21.02.2019.

4              We have heard the complainant and have also gone through the documents placed on file carefully.

5.             The complainant purchased a mediclaim policy  no.PROHLR980158135, valid from 22.09.2018 to 21.09.2019 from OP no.1. The said policy is for entire family of the complainant which is consisting of his wife, son and daughter. On 22.10.2018 at about 4.00 p.m. the complainant suffered from high grade fever, cough with expectoration, severe headache, severe generalized weakness, nausea. His condition was critical and as such he was admitted in the Park Hospital where remained admitted uptill 27.10.2018.  OP no.2 gave the estimate of treatment of the complainant of Rs.47500/- to the OP no.1 and OP approved the claim of Rs.25,000/- and it was observed that the remaining amount of Rs.22,500/- would be paid by the complainant. But lateron OP no.1 repudiated the entire claim of the complainant on the ground that insured person during the first 30 days from the inception date of the policy will not be covered. The said plea taken by the OP is null and void because the 30 days period of the policy was completed on 21.10.2018 and the complaint fell ill on 22.10.2018 and was admitted at 4.25 p.m. in the hospital. In support of his allegations complainant filed his affidavit Ex.CW1/A and documents Ex.C1 and Ex.C12. To rebut the evidence produced by the complainant OPs did not appear and opted to be proceeded against exparte. Thus evidence of the complainant has gone completely unrebutted and unchallenged, therefore, there is no reason to disbelieve the same. Hence, it is well proved that the service of the OPs was deficient in repudiating the claim of the complainant.

6.             As a sequel to the foregoing reasons, we accept the present complaint and direct the OPs to pay Rs.43247/- to the complainant with interest @ 9% per annum from the date of repudiation of the claim of the complainant till its realization. We further direct the OPs to pay Rs.15000/- to the complainant on account of mental agony and harassment suffered by him and for the litigation expenses. This order shall be complied within 30 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:28.02.2019

                                                                       

                                                                  President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

               

        (Vineet Kaushik)          (Dr. Rekha Chaudhary)

            Member                               Member