Delhi

New Delhi

CC/953/2008

Jitender Prakash Tiwari - Complainant(s)

Versus

M/S. Insant Healthcare Pvt.Ltd. & Anr. - Opp.Party(s)

05 Mar 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/953/08                                                                                                                                                                               Dated:

In the matter of:

SH. JITENDER PRAKASH TIWARI

S/O SH. B N Tiwari,

R/OG-56, GREEN PARK MAIN,

NEW DELHI-110016

 

                   ……..COMPLAINANT

 

VERSUS

 

1.INSANT HEALTHCARE PVT. LTD.

 

2.NATIONAL INSURANCE COMPANY LTD.,

DO-XIV, STERLING CINEMA BNUILDING, 2^ND FLOOR,65 MARJBAN STREET, FORT, MUMBAI-01

 

 

………. OPPOSITE PARTY

 

ORDER

 

Member :  Ritu Garodia

 

The complaint pertains to non-settlement of medi-claim by OPs. 

The factual position of complaint is that complainant was issued Policy by OP 1 & OP2 from 2.11.2006 to 1.11.2007 for a sum of Rs.1,50,000/- vide NIC Reference No.260600/46/06/8500000605 after payment of premium of Rs.4,584/- vide cheque No.205305 dated 1.11.06.  OP1 & OP2 are TPA (third Party Administratory) of OP3.  The receipt of premium and cover note issued by OP1 & OP2 are annexed with the complainant.  The complainant had an accident on 7.6.2007 and was hospitalized.  He was subsequently diagnosed with “Bilateral Hydrocelf with L/O Trauma and incurred an expenditure of Rs.18,050/- (photocopy of bills are enclosed).  Complainant lodged a claim with OP 2. Claim form is annexed with complaint.  A legal notice was issued to OPs on 16.12.07.  Proof of delivery annexed with complaint.

OP2 i.e. TPA by a letter dated 30.10.07 had repudiated the claim as not payable under clause 4.3 under which the said claim is payable only after 24 months of continuation of policy (OP’s letter annexed as page 36 of complaint).  Further, OP2 by a letter dated 9.1.08 has repudiated the claim by giving reference of letter of OP 3 i.e the insurance company dated 20.12.07, wherein it was stated that their office has cancelled all policies which were issued by OP-1 with effect from 26.3.2007 and premium was refunded.  The letter also states that during the period of hospitalization, they were not covering the risk and insured is advised to take up this matter with TPA i.e. OP 1 & OP 2.  (The letter annexed with the complaint on page 33-35)  OP 1 & OP 2 failed to appear and present their version despite several notices sent to them.  OP 3 in its WS has submitted that the policy in question was terminated on 26.3.07 much before the date of accident i.e. 07.06.07.   OP 3 has also denied that complainant had an accident and was subsequently hospitalized. 

 

We have perused the record, pleading and correspondence annexed by both parties.  The aforesaid policy has been admitted by all parties.  However, as admitted by OP 3, their policies with OP 1 were cancelled w.e.f. 26.3.2007.  There is no intimation to complainant regarding cancellation either by OP 1 and OP 2 or OP 3.  OP 3 being a insurance company failed to act in a prudent manner while cancellation of policy.  OP-3 has not adduced an iota of evidence regarding the refund of premium to the insured   The helpless consumer/insured after paying the premium was assured that his health risk was covered.  Complainant’s mortification and shock can only be imagined that on getting hospitalized, he was informed after 6 months of pursuing all OP’s that due to some internal problem/mismanagement among OPs his insurance policy stands unilaterally cancelled. It is a very serious matter.  In case of a public insurance company like OP3, it would show that the laid down guideline and procedure for intimation regarding the cancellation of policy has not been followed.

As there is no proof of refund of premium nor any evidence regarding communication to the insured for cancellation of policy, deficiency is clearly established.

We, therefore we hold all OPs jointly and severally liable and directed them to pay Rs.18,050/-.  (Complainant expenses incurred in hospitalization) with 9% interest from date of claim till realization.  We also award Rs.25,000/- as compensation for harassment, mental agony physical inconvenience inclusive of litigation expenses.

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

Copy of the order be sent to the parties free

of cost.

Pronounced in open Court on 05.03.2015.

 

(C.K.CHATURVEDI)

PRESIDENT

 

 

(S.R. CHAUDHARY)               (RITU GARODIA)

MEMBER                                 MEMBER