Delhi

New Delhi

CC/1268/2009

Sushil Kumar - Complainant(s)

Versus

M/S. Instant Health Care Pvt.Ltd. - Opp.Party(s)

24 Nov 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/1268/09                  Dated:

In the matter of:

Sushil Kumar,

E-4/137, Sector-7, Rohini,

Delhi-85

……..COMPLAINANT

         

VERSUS

 

 

1. Instant Health Care Pvt. Ltd.,

1111, Antriksh Bhawan, K.G Marg,

Connaught Place, Delhi-110001

 

2. United India Insurance Co. Ltd.,

Kirti Place, Kriti Nagar, Delhi-15

 

                                        ………. OPPOSITE PARTIES

 

ORDER

Member: Ritu Garodia

The Complaint pertains to repudiation of medi claim. A medi claim policy was purchased from OP vide reference no.221600/48/07/41/00001598 for a periods from 31.08.07 to 30.08.08. OP was admitted in AIIMS from 06.09.07 to 07.09.07 and underwent treatment. A claim was filed. However, it was repudiated by letter dated 14.01.08 under an exclusion clause.

OP2 in its version has stated that claim has been denied as per opinion of TPA and claim falls under exclusion clause of terms and condition of policy as annexed.

Careful scrutiny of documents of OP reveals that neither opinion of TPA nor terms and conditions of policy are annexed. Complainant was directed to file discharge summary and bills paid for expenses. Complainant has filed OPD card of AIIMS which states that the complainant has chronic CSR (Central serous Retinopathy) for which PDT was recommended which was apparently done on 06.09.07. Complainant has placed a certificate by HDFC Bank where he is an account holder showing that Rs.60,000/- has been issued from account of M/s. Ambay Trading Company having Mr. Sushil Garg as proprietor in favor of Dr. R.P centre, AIIMS, New Delhi which was cleared on 13.09.07.

In our considered view, OP is guilty of deficiency in arbitrarily repudiating the claim on grounds which are unsupported by any evidence.  Even the exclusion clause is not mentioned in the reply or evidence of OP. The Complainant mean while suffered unnecessarily while being covered by medi claim policy for relevant period. We therefore direct OP2 to settle the claim by paying Rs.60,000/- with 9% interest from date of claim till repayment. We also award Rs.25,000/- towards harassment caused to person insured and Rs.10,000/- as litigation expenses.

The order shall be complied 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.

File be consigned to record room.

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

 

 

          Pronounced in open Court on ……………….

 

 

                       

(C.K.CHATURVEDI)

PRESIDENT

          (RITU GARODIA)

                                         MEMBER