DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II

Udyog Sadan, C-22 & 23, Qutub Institutional Area

(Behind Qutub Hotel), New Delhi-110016.

Case No. 675/2012

1. Sh. Pradeep Kr. Arya

2. Smt. Sneha Arya

Both Residents of B-11,

Gujrawala Apartments,

Vikas Puri, New Delhi                                              ...Complainants

Versus

Max Bupa Health Insurance Company

Through its General manager

Having Corporate Office at:

Second Floor, Salcon Ras Vilas D-1

District Centre, Saket

New Delhi – 110017                                                  …Opposite Party

                                                Date of Institution          :        17.12.2012                                              Date of Order        :         06.06.2016

Coram:

Sh. N.K. Goel, President

Sh. S.S. Fonia, Member

O R D E R

          Briefly stated the case of the Complainants is that they  had jointly procured insurance policy bearing No. 2006438620110 with customer ID No. 0000076731 towards mediclaim policy from the OP.  They had got it transferred from previous insurance policy. Complainant-2 Sneha Arya suffered severe pain in abdomen and heavy bleeding on 10.4.2012 and was admitted to the Sai Nursing Home, A-3/18, Janakpuri, New Delhi. She was discharged after treatment on 13.4.2012.  The complainant filed claim of Rs.42,597/-, out of which Rs. 41469/- was spent on inpatient treatment  and Rs. 1128/- was spent on post hospitalization.  The claim was submitted to the OP on 23.4.2012 vide reference no. 126015.  Initially the OP is said to have promised to the complainant to release the payment but later on OP refused the claim for the reason of earlier hospitalization of complainant-2 Sneha Arya on  14.10.2011.  The complainants state that they obtained a certificate from Sai Nursing Home through one Dr. Anshu Arora  which clearly states that earlier hospitalization of the complainant-2 on 14.10.2011 was for undergoing D+C and again she was admitted on 10.4.2012 for severe pain abdomen and heavy bleeding and undergone hysterectomy.  According to the said certificate D+C and hysterectomy were not interrelated.  The said certificate is said to have been given to the OP by the complainants but till date their claim has not been settled. Thereafter, Complainants sent legal notice to the OP on 11.9.12 asking for releasing claim amount along but to no avail. Feeling aggrieved complainants have invoked jurisdiction of this Forum claiming deficiency in service on the part of the OP and prayed for issuing directions to the OP to pay Rs.42597/- being the claim amount along with interest @ 24% p.a., Rs. 2 Lacs as compensation for mental agony, physical pain, suffering etc. and  Rs. 25,000/- as cost of litigation. 

          OP has been proceeded exparte vide order dated 6.3.2013 passed by our Predecessors.

          Complainant-1 has tendered evidence by way of affidavit.  Complainant-2, namely, Sneha Arya has also tendered evidence by way of affidavit.

          Though none of the complainants have exhibited any documents yet we find several documents from page No. 16 to 37 containing various documents in support of treatment expenses and medical certificates etc. in the affidavit of Sneha Arya

          Written submissions have been filed by the complainants.

          We have heard counsel for the complainants and have also gone through the record very carefully.

          Now, we straightway advert to the main issue, whether the complaint is bonafide and, if so, whether prayer is admissible.

           Legal notice sent to the OP by the advocate of the complainant dated 11.9.2012 is on the record.

          Averments made in the complaint and evidence led by the Complainant have remained uncontroverted and unchallenged. Hence, there is no reason to disbelieve the versions of the Complainant.

We, therefore, draw adverse inference that OP has deliberately  avoided to contest the claim of the complainants which amounts to admission of their legal obligation in the eyes of law  towards the reimbursement of mediclaim.  On the other hand, complainant have produced documentary evidence in support of medical expenses for Rs.41,469/- excluding Rs.1128/- towards  post hospitalization.

           In view of above discussion, we allow the complaint and direct OP to pay a sum of Rs. 42,597/- towards medical expenses incurred by the complainant-2 for her treatment  in Sai Nursing Home along with Rs. 5% interest  p.a. from the date of  submission of the claim i.e. 23.4.2012 and Rs. 20,000/- towards compensation for mental agony and legal expenses within 30 days of receipt of copy of this order failing which OP shall become liable to pay the said amount of Rs.42,597/- along with interest @ Rs. 9% per annum from 23.04.12 till its realization.

           Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations.  Thereafter file be consigned to record room.

Announced on   06.06.16.

(S.S.FONIA)                                                                                                                                                                              (N.K. GOEL)    MEMBER                                                                                                                                                                                 PRESIDENT