Delhi

New Delhi

CC/953/2012

Kanhaiya Priyadarshi - Complainant(s)

Versus

M/S. New India Assurance Company Ltd. - Opp.Party(s)

26 Oct 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/953/12                                                                                                                                                                               Dated:

In the matter of:

Kanhaiya Priyadarshi

S/o Sh. S.Y Diwakar,

R/o A-307, Ashiana the heritage, Plot no.14,

Vasihali, Ghaziabad-201010

……..COMPLAINANT

       

VERSUS

1. New India Insurance Co. Ltd.,

        Delhi Regional Office-I, Jeevan Bharti Bldg.,

        124, Connaught Circus,

        New Delhi-110001

        Also at:

        Delhi Regional Office-II,

        10^th Floor, Core-I, Scopr Minar, Laxmi Nagar District Centre, Delhi-92

 

2. TTK Helath Care TPA Pvt. Ltd.,

B-25, 1^st Floor, Sec-1, Behind Indian Oil Building, Noida-201301

 

3. CITI Bank N.A,

124, Jeevan Bharti Building,

3^rd Floor, Connaught Circus, New Delhi-110001

 

                         ………. OPPOSITE PARTIES

 

ORDER

President:  C.K Chaturvedi

The complainant is covered under a good health policy Diners Credit Card issued to father of the complainant. The other family members are also covered. The policy is mandatory and auto renewable by Diners card, for which authorization is assumed, unless covered persons opts out after giving notice of 30 days.

The Complainant had some ear discharge problem and he took consultation of Dr. Dhingra at Apollo Hospital where doctor advised him a surgical procedure at a cost of Rs.70,000/-. The TPA was contacted for cashless, but it was denied, as in 2002, the complainant had a surgery of ear. The Complainant’s father got the surgery conducted and paid the total bill of Rs.90,000/- from his resources and presented the claim, with treatment record etc. The OP repudiated the whole claim, stating it to be a case of pre-existing disease firstly as complications of pre-existing disease and secondly that it was within 48 months of the policy. The concerned doctor and all consultation paper on record mentioned the earlier disorder in 2002, and noted the present symptoms of giddiness, loss of hearing and ear discharge when patient came. But in the claim Form he by inadvertently mentioned 1 year of these symptoms. The doctor issued a clarification certificate on record, but OP did not agree.

We have considered the reply and original treatment paper on record and reply of OP in terms of its exclusion clauses. We find that Annexure C3, on page 22 of the complaint is the first diagnose of Dr. P.L Dhingra on 09.03.12 which records earlier surgery of 19.04.02 and mentions present complaint of giddiness, repeat infection and wax collection. It does not mention any period of complaint. He advised for cavity revision and has clarified in his letter dated 30.06.12, which is Annexure C11 at page 62 of complaint that it was not a case of complication but a sequel to it. In claim form also he did not describe it as pre-existing.

In our considered view, this is a genuine claim, which is freely explained by treating doctor, and OP has not other material except its own reading of treatment paper to reform the claim; without any substance in the fact of the case. We hold OP liable for reimbursement and hold it liable for deficiency and direct it to pay Rs.83,771/- claimed by complainant  and pay Rs.25,000/- for deficiency and 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 26.10.2015.

 

(C.K.CHATURVEDI)

PRESIDENT

 

 

 

 (RITU GARODIA)

MEMBER