Delhi

StateCommission

A/11/557

NIA CO. LTD. - Complainant(s)

Versus

MAHESH KR. DHINGRA - Opp.Party(s)

24 Aug 2015

ORDER

IN THE STATE COMMISSION: DELHI

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

                                                   Date of Decision: 24.08.2015

First Appeal No. 557/2011

(Arising out of the order dated 21.07.2011 passed in complaint case No. 1435/2008 by the District Consumer Disputes Redressal Forum-VI, Barracks Kasturba Gandhi Marg, New Delhi-01)

In the matter of:

The New India Assurance Co. Ltd.

(Through its Delhi Regional Office-II)

2/1, IInd Floor, Jeevan Raksha Building

Asaf Ali Road, New Delhi-110001                  Appellant

 

Versus

 

Mahesh Kumar Dhingra

S/o Late Sh. Jassu Ram

R/o House No. H-42

Kalkaji, New Delhi-19                                   Respondent

                                                                  

          CORAM

 

SH N P KAUSHIK                               -                      Member (Judicial)

SH. S.C. JAIN                                    -                      Member

 

1.         Whether reporters of local newspaper be allowed to see the judgment? Yes

2.         To be referred to the reporter or not? Yes

 

N P KAUSHIK – MEMBER (JUDICIAL)

JUDGMENT

1.          Present appeal is directed against the orders dt. 21.07.2011 passed by the Ld. District Forum-VI, New Delhi. Vide impugned orders Ld. District Forum held the OP/appellant herein (New India Insurance Co. Ltd.) guilty of deficiency of service. Ld. District Forum held that the complainant was clearly entitled to the cashless facility and the claim was arbitrarily rejected. Insurance Company i.e. OP-1 was directed to clear the claim for payment within thirty days. Compensation and litigation charges to the tune of Rs. 50,000/- were also awarded. It was also held that in case the claim is not paid in thirty days of the submission of papers, OP-1 (New India Insurance Company) shall pay interest @ 9% p.a. for the period of delay.
2.          In brief, the complainant had insured himself and his wife for a sum of Rs. 2,00,000/- for the period from 01.06.2007 to 31.05.2008. In the third week of January 2008 complainant noticed a small wound/ulcer under his left foot. After getting treatment from two doctors, complainant visited Max Devki Devi Heart and Vascular Institute on 25.02.2008. Doppler test showed that the complainant had been suffering from Peripheral Arterial Disease. Arteries of left leg were blocked.  Operation of the Peripheral Reascutaneous i.e. PTA of left SFA to remove the blockages was done. Thereafter main operation was done for which the patient/complainant remained hospitalised from 14.03.2008 to 17.03.2008. He had to spend more than Rs. 2 Lac. OP-1 (New India Insurance Co. Ltd.) repudiated cashless claim stating that it was a case of pre-existing disease and possibility of long standing pathology cannot be ruled out. During the course of arguments the appellant/New India Insurance Co. Ltd. processed the claim on the basis of documents in its possession. In other words it was felt that there was no need of the complainant preferring the fresh claim to OP-1. The insurance Company vide its e-mail dt. 18.08.2015 repudiated the claim on the grounds which are reproduced below:

“From the claim papers it is understood that the claimant is a known case of DM & HT and a chronic smoker. As it is fresh policy and the presence of DM & HT contributing to current ailment cannot be ruled out. The claim therefore is not admissible under PED exclusion and the repudiation is in order.”

 

The e-mail is exhibited as exhibited C-1 while dictating these orders.

3.          Claim has been repudiated on the grounds that the complainant’s case was a case of diabetes mellitus and hypertension. Being chronic smoker contribution of the diabetes/hypertension to current ailment cannot be ruled out. Perusal of the authorisation request dt. 25.02.2008 prepared by the Max Devki Devi (OP-3) shows that the complainant was suffering from diabetes for the past six months and for hypertension for the last two months only. Doctors having observed that either diabetes or hypertension have contributed to the blockage of the arteries. In the circumstances we do not find any illegality or infirmity in the orders passed by the Ld. District Forum.
4.          As observed above, repudiation of the claim by OP-1 as per document exhibit C-1 is again without any basis. No material has been placed on record by the appellant herein to support its contention that the current ailment was either due to diabetes or hypertension. Repudiation thus is not sustainable in the eyes of law. Appeal on this count too is dismissed. It is further made clear that insurance company (New India Insurance Co. Ltd.) OP-1 shall not be liable to pay interest within the period of thirty days of submission of papers as directed by the Ld. District Forum. Since the claim as such has been rejected by the OP-1 vide e-mail exhibit C-1, let the same be paid to the complainant within a period of forty five days from today. In the event of failure of the appellant herein to comply with the orders, appellant shall be liable to pay interest @ 9% p.a. on the said amount after expiry of period of forty five days from today. In view of the changed scenario, compensation of Rs. 50,000/- imposed upon the appellant herein is also waived.
5.          Copy of the orders be made available to the parties free of costs as per rules and thereafter the file be consigned to Records.
6.          FDR, if any, deposited by the appellant be released as per rules.

(N P KAUSHIK)

MEMBER (JUDICIAL)

 

 

(S C JAIN)
MEMBER