Delhi

West Delhi

CC/10/342

SOMAN LAL BANSAL - Complainant(s)

Versus

IFFCO TOKIO GENERAL INSURANCE - Opp.Party(s)

31 Jan 2019

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (WEST)

        150-151; COMMUNINTY CENTER ; C-BLOCK; JANAK PURI; NEW DELHI

 

CASE NO. 342/10

 

Sh. Soman Lal Bansal

Son of Sh. Raghunath Shahi

R/o RZ-14/248, Geetanjali park, 

Gali No. 3, West Sagarpur,

New Delhi-110046.                                                           …… Complainant

VERSUS

1. IFFCO TOKIO General Insurance Co. Ltd.

SBU, 4^th Floor,

416-421, NarainManzil -23,

Barakhama Raod ,

New Delhi-110001....…Opposite Party No. 1

 

2. Sambhoo Saran Pandey, Agent

           S/o Chkkardhar

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (WEST)

        150-151; COMMUNINTY CENTER ; C-BLOCK; JANAK PURI; NEW DELHI

 

CASE NO. 342/10

 

Sh. Soman Lal Bansal

Son of Sh. Raghunath Shahi

R/o RZ-14/248, Geetanjali park, 

Gali No. 3, West Sagarpur,

New Delhi-110046.                                                           …… Complainant

VERSUS

1. IFFCO TOKIO General Insurance Co. Ltd.

SBU, 4^th Floor,

416-421, NarainManzil -23,

Barakhama Raod ,

New Delhi-110001....…Opposite Party No. 1

 

2. Sambhoo Saran Pandey, Agent

S/o Chkkardhar

IFFCO TOKIO General Insurance Co. 

Office D-2/48-49,

Janakpuri, New Delhi.……Opposite Party No. 2

 

 

O R D E R

 

 

K.S. MOHI, PRESIDENT

 

The complainant has filed the present complaint against the O.P under section 12 of Consumer Protection Act, 1986.  The facts as alleged in the complaint are that the complainant had initially taken mediclaim policy  in 2007  through OP -2  who is the agent of OP-1 and   the policy was continued till date  of the institution  of the complaint.  It is further averred in the complaint that in the month of Aril, 2009 the complainant suddenly developed some problem in his abdomen  for which  he was taken to  Kesar Nursing  Home, Vashist Park,  Pankha Raod, New Delhi on 20.04.2009.  He had  gone through  certain diagnostic   tests and was found to be suffering  from Umbillicas Harnia and on the advice of the doctor had under gone operation  called Mesh Hernipolasty C- Umbilectomy of the said ailment.  The complainant remained  admitted in the hospital from 23.04.2009   to 25.04.2009  and incurred  medical expenses to the tune of Rs. 34,442/-   for which  he lodged claim with OP for reimbursement  of medical expense.  However, the OP did not process the claim nor send him any intimation regarding the fate of claim.  OP illegally withheld the claim of complainant which amounted to deficiency in service. Hence the present complaint.

2. The OP  filed written statementtaking preliminary objections that as per terms and condition of insurance policy, in order to  enable  the processing and consideration of claim, the complainant was required to furnish certain  medical details /documents alongwith  claim.  However, the complainant  failed to furnish he aforesaid documents.  Complainant was duly informed by TPA  to supply  said documents but the  complainant did not respond.  Even the reminders in this regard did not  move the complainant to do the needful.  As such complainant violated clause 6 which dealt with claim procedure and requirement.   The claim of the complainant  could not  be  processed with in the absence of requisite record pertaining to medical treatment.  However, the policy is not disputed by OP.

3.     Complainant has filed replication denying contents of written statement and re-affirming the contents of complaint.  He has filed his affidavit in evidence testifying all the facts stated in the complaint and filed documents  Ex.CW1/1 to Ex.CW1/9.   On the other hand Sh. Saikat  Sarkar Asstt.  Vice President   filed affidavit of evidence on behalf of OP.

4.     We have heard Counsel for parties and perused the record.

5.     The controversy involved in the present case lies in a narrow campus.  The perusal of written statement filed of OP would show that the only defense taken by OP is that till filing of complaint no original documents /bills /discharge slip were submitted by the complainant to OP and that OP  was still ready to process  the matter if original documents were furnished.  This Forum during the course of proceedings directed the complainant to supply all the relevant documents  to OP .  On 30.04.2013   the certified copy of document were supplied to Counsel for OP-I. Unfortunately even after submission of certified copy of medical record OP did not take steps to  assess or settle the claim  which  prima-facie  amounted to deficiency on part of the OP.  Needless to say that OP has not contested or denied the policy/medical treatment/medical expenses ,therefore, we have  no hesitation to accept the complaint. 

 

6.     Keeping in view the discussion  and circumstance stated above we award a sum of Rs3,4,442/- in favour of complainant and against OP to be paid  within 45 days from receipt of this order failing which  interest @ 6% from the date of institution  of complaint till realization.  The complainant is also awarded  a sum of Rs. 10,000/- towards  mental agony, harassment  and litigation expenses.

Copy of this order be sent to the parties as per rules.

File be consigned to the record room. 

  Announced this____31__ day of __January__ 2019.

 

                                                                                                                       ( K.S. MOHI )                                                   (PUNEET LAMBA)                                                                                  PRESIDENT                                                    

 MEMBER