CONSUMER DISPUTES REDRESSAL FORUM – X
GOVERNMENT OF N.C.T. OF DELHI
Udyog Sadan, C – 22 & 23, Institutional Area
(Behind Qutub Hotel)
New Delhi – 110 016
Case No.202/2008
MR. NIPUN
S/O SH. RADHEY SHYAM
R/O C-185/10 GALI NO.10,
C-BLOCK, AMBEDKAR VIHAR,
JOHRIPUR, DELHI-110094
…………. COMPLAINANT
Vs.
- M/S IFFCO TOKIO GENERAL INSURANCE CO. LTD.
REGD. OFFICE:- 34, NEHRU PLACE,
NEW DELHI-110019
THROUGH MANAGER
- PARAMOUNT HEALTH SERVICE PVT. LTD.
GOLDEN MULTI-SERVICES CLUB
G.T.F.S. BUILDING, II FLOOR,
17A/53, W.E.A. KAROL BAGH,
NEW DELHI-110005
THROUGH ITS MANAGER
…………..RESPONDENT
Date of Order: 18.05.2016
O R D E R
A.S. Yadav – President
The case of the complainant is that he is para-medical policy holder issued by OP-1 for the period 15.08.2006 to 14.08.2007. Complainant had a Fracture Mendable Jaw C and RTA and opened Head Injury and for that he was admitted in Mavi Nursing Home, Indira Puri, Shanti Nagar, Loni, Ghaziabad on 04.03.2007. Complainant was treated there and was discharged on 08.03.2007. Complainant spent total amount of Rs.15,195/- on treatment and submitted the bill to OP-1 for reimbursement but his claim was rejected by OP-1 on the ground that the claim documents forwarded to them were not in proper format, as such the claim cannot be processed further and the claim was closed. It is stated that it is a clear cut case of deficiency in service on the part of OP-1. Accordingly, this complaint has been filed whereby it is prayed that OP be directed to pay Rs.15,195/- as medical claim alongwith interest @ 24% p.a. and also to pay Rs.35,000/- as compensation.
OP-1 is insurer and OP-2 is TPA of OP-1. OP-1 in the reply has not disputed the fact that the complaint was duly insured during the relevant period. It is not in dispute that the complainant submitted the claim form alongwith documents. The only plea taken by OP-1 is that the name of the doctor who treated complainant has not been disclosed and also that X-ray report etc. were not handed over.
OP-2 in the reply took the plea that it is the duty of OP-1 to reimburse the claim ad OP-2 is only the facilitator of OP-1.
We have heard Ld. Counsel for the parties and carefully perused the record.
Complaint has placed on record the Claim Form which was filled up in the printed proforma of OP-1 only. It contains all the details of the claim. Alongiwith claim form, complainant has annexed all necessary bills including the bill issued at the time of discharge i.e. on 08.03.2007 for a sum of Rs.15,195/-. The bill contains all the details including the name of doctor who treated the complainant. Alongwith bill all the receipts have been annexed. We failed to find any plausible reason on the part of OP-1 to reject the claim. The claim has been rejected on very specious ground that documents are not in proper format, hence claim was not processed. The claim was submitted on printed proforma of OP-1, necessary documents were annexed. The plea of OP-1 that the X-ray report etc. were not submitted is without any basis as in the rejection letter dated 30.07.2007, it is nowhere stated that the X-ray report has not been submitted. Even otherwise complainant in the rejoinder has specifically stated that he has submitted all the necessary documents and documents were duly received by OP-1 as is evident from the claim form.
It is clear cut case of deficiency in service on the part of OP-1.
OP-1 is directed to refund Rs.15,195/- to complainant alongwith interest @ 9% p.a. from April 2007. OP-1 is further directed to pay Rs.8,000/- towards compensation and Rs.3,000/- towards litigation expenses.
Let the order be complied with within one month of the receipt thereof. The complaint stands disposed of accordingly.
Copy of order be sent to the parties, free of cost, and thereafter file be consigned to record room.
(D.R. TAMTA) (A.S. YADAV)
MEMBER PRESIDENT
