Delhi

New Delhi

CC/714/2009

Suresh Kataria - Complainant(s)

Versus

M/S. Bajaj Allianz General Insurance Company Ltd. - Opp.Party(s)

19 May 2015

ORDER

CONSUMER DISPUTES REDRESSAL FORUM-VI

(DISTT. NEW DELHI), ‘M’ BLOCK, 1^STFLOOR,

VIKAS BHAWAN, I.P.ESTATE,

NEW DELHI-110002.

 

Case No.CC/714/09                                                                                                                                                                               Dated:

In the matter of:

Suresh Kataria,

B-28, Nanda Road, Sarai Extension,

Adarsh Nagar, Delhi-33

 

……..COMPLAINANT

       

VERSUS

1. Bajaj Allianz General Insurance Co. Ltd.,

        C-31/32, Inner Circle, Opp. PVR Plaza,

        Connaught Place, New Delhi

 

2. JMC Projects (India) Ltd.,

        331-334, Somdutt Chambers-II,

        9, Bhikaji Cama Palabce, New Delhi-110066

 

                                         ……. OPPOSITE PARTIES

 

ORDER

Member: S.R Chaudhary

 

The Complainant being a professional had taken a medi claim policy under group insurance cheme for self and spouse with a validity period of 29.12.07 by OP2 on behalf of OP1. During the month of July 2007, the complainant while at site of working place accidently slipped and fell down and knee was injured and was admitted in Parmanand Hospital Civil Lines and incurred expense was Rs.58,604/- as per Exh.2 and discharge slip dated 19.10.07 but OP repudiated the claim stating “Pre-existing Diseases” as per Exh.3. Thus, complaint was filed.

It appears from OP1 evidence Para2 that the claim was repudiated on 26.11.07 on the basis of “Pre-existing Diseases” as per exclusion 4.1 whereas Discharge summary provided by Hospital Doctor giving remarks mentioned as under:

 “Patient is apparently well four months back when he has an incidence of twisting of left knee after which he has pain and discomfort”

Further OP admitted policy in question covering period 14.05.07 to 13.05.08 on merit and also not disputed expenses incurred was Rs.58,604/-. Complainant replied in rejoinder that the averments to be considered as admission on behalf of OP2 for all the contents of complaint.

As per OP1 evidence Para4 rejected the claim on the basis of pre-existing disease for one year six months while doctor admitted in discharge slip that due to incident of sudden fall 4 months back, left knee had pain and discomfort which appears that it is clear case of deficiency on the part of OP to repudiate the claim arbitrarily taking shelter of pre-existing diseases. The OP cannot consider injury as a pre-existing disease.

 Thus, holding OP guilty, we direct OP to pay Rs.58,604/- along with 9% interest per annum from the date of claim till realization. We also award Rs.25,000/- for harassment inclusive of litigation expenses.

The order shall be complied within 30 days of the receipt of the copy of the order; otherwise action can be taken against OP under Section 25/27 of the Consumer Protection Act.

File be consigned to record room.

Copy of the order be sent to the parties free of cost.

 

 

        Pronounced in open Court on 19.05.2015.

 

 

(C.K.CHATURVEDI)

PRESIDENT

 

 

(S.R. CHAUDHARY)                 (Ritu Garodia)

MEMBER                                  MEMBER