Delhi

StateCommission

A/278/2017

M/S IFFCO TOKIO GENERAL INSURANCE COMPANY LTD. - Complainant(s)

Versus

DINESH SAHAI - Opp.Party(s)

ABHINAV JAIN

18 Nov 2019

ORDER

IN THE STATE COMMISSION : DELHI

(Constituted under Section 9 of the Consumer Protection Act, 1986)

Date of Arguments :18.11.2019

Date of Decision :21.11.2019

FIRST APPEAL NO.278/2017

In the matter of:

 

1. Iffco Tokio General Insurance Co.,

Regd. Office-34, Nehru Place,

New Delhi-110019.

 

2. Paramount Health Services Pvt. Ltd.

AB-15, Sector-1, Ground Floor,

Enclave-II, Salt Lake City, Kolkatta-700064.

 

Also at:-

Paramount Health Services Pvt Ltd.,

B-2, IIIrd Floor, G.K. Enclave-II, new Delhi-110048.

 

3. Golden Multi Services Club Ltd.,

16. R.N. Mukhrjee Road, Kolkatta-700001.

 

Also at:-

 

Golden Multi Services Club ltd.

17-A/53 WEA 2^nd Floor, Gurudrara Road,

Karol Bagh, New Delhi-110005.                                            ………Appellant

 

Versus

 

Dr. Dinesh Sahai,

R/o. A-23, Shekhar Apartments,

Mayur Vihar, Delhi-110091.………Respondent

 

 

CORAM

Hon’ble Sh. O. P. Gupta, Member (Judicial)

1.     Whether reporters of local newspaper be allowed to see the judgment?                                                      Yes/No

2.      To be referred to the reporter or not?                                                                                                           Yes/No

Shri O.P. Gupta, Member (Judicial)

 

 

JUDGEMENT

 

1. The present appeal is directed against order dated 07.04.17 passed by District Forum in CC npo.191/2008  vide which the complaint was allowed and OP/ appellant was directed to pay Rs.2,38,297/- with interest @9% p.a. from the date of claim till payment, Rs.25,000/- as compensation towards harassment and Rs.10,000/- as litigation expenses. The facts of the case as recited in the impugned order are that respondent/ complainant obtained a medical insurance. He was admitted in emergency as Escort Heart Institute and Research Centre, New Delhi on 29.12.06. He applied for cashless claim which was denied   vide letter dated 30.12.06. He  was discharged from the hospital on 01.01.07. He paid bill of Rs.2,38,297/- and filed a claim with the appellant. The respondent sent letter dated 05.04.07 closing the claim due to non submission of documents. Complainant submitted documents. OP again closed the case vide letter dated 20.06.07.
2. The appellant took objection of territorial jurisdiction and the defence of pre existing disease.
3. The District Forum found that appellant has not placed an iota of evidence showing that respondent was suffering from coronary artery disease before inception of policy or was taking treatment for the same. The District Forum  also found that OP has failed to show that complainant was aware that he was having the coronary artery disease earlier. A person may be  suffering from  multiple disease and may not be aware of it. Hence the complaint was allowed.
4. The respondent was served for 20.12.17 and put in appearance through his counsel Shri Ravi Goptal who filed memo of appearance. Copy of appeal and application for condonation of delay was supplied. He was directed  to file reply within 8 weeks. Another opportunity to do so was given vide order dated 13.09.18. On the next dated i.e. 03.05.19 none appeared for the respondent and he was proceeded exparte. Delay of 6 days in filing appeal was condoned vide same order.
5. I have gone through the material on record and heard the arguments. The counsel for appellant confined his  arguments to the fact that an insured cannot claim more than the amount for which he takes insurance. He drew my attention towards copy of the policy at page 18 which shows that the appellant took policy for himself to the tune of Rs.1 lakh. In these circumstances the District Forum was not justified in awarding the full sum of Rs.2,38,297/-.
6. The appeal is accepted in part , impugned order is modified to the effect that appellant will pay Rs.1 lakh with interest @9% p.a. from the date of claim till payment and Rs.10,000/- as litigation expenses. The compensation of Rs.25,000/-  towards harassment is set aside.
7. The appeal is disposed of accordingly.
8. Copy of the order be sent to both the parties free of cost.
9. One copy of the order be sent to District Forum for information.
10. File be consigned to record room.

 

 

 

(O.P. GUPTA)                                                     

MEMBER (JUDICIAL)