Delhi

New Delhi

CC/1031/2013

Sunender Bansal - Complainant(s)

Versus

M/S. Oriental Insurance Company Pvt.Ltd. - Opp.Party(s)

07 Apr 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/1031/13                                                                                                                                                                              Dated:

In the matter of:

SHRI SURINDER BANSAL,

R/O.R-65 VANI VIHAR

UTTAM NAGAR, NEW DELHI-110059.

               

 ……..COMPLAINANT

       

VERSUS

 

THE ORIENTAL INSURANCE CO. LTD.

88, JANPATH, GROUND FLOOR,

NEW DELHI-01

 

………. OPPOSITE PARTY

 

ORDER  [ ORAL]

 

CORAM:   PRESIDENT: C.K.CHATURVEDI

MEMBER: S.R. CHAUDHARY           

MEMBER: RITU GARODIA

                               

 

Present Parties

Argument heard

Member: Ritu Garodia

We have summarily considered the matter in the light of submission and material on record. The short facts of alleged deficiency is that complainant, took a Medi-claim Policy bearing No.27200/48/2013/2360 from 22.5.13 to 21.5.14.  Complainant was admitted in Action Medical Centre and Mata Channan Devi Hospital during the insured period and incurred an expense of Rs.19,488/- and Rs.1,30,000/- respectively and presented the claim which was repudiated.  The Bills are annexed with complainant the Discharge Summary reveals the diagnosis as “Type 2 DM, CAD Acute AWM1 DVD, Primary PTCA to LAD (IRA)” and Procedure done as “CAG & PTCA stunt to LAD”.

        OP repudiated the claim on execution clause 4.2 wherein diabetes has been excluded in first two years of policy.

        Perusal of discharge summary reveals that Procedure/surgery done was CAG i.e Cardio Angio Graphy and PTCA stent.  There is no treatment undertaken by treating hospitals regarding diabetes.  OP has not placed and cogent and convincing evidence showing any treatment undertaken for diabetes and therefore unfairly and arbitrarily repudiated the claim on ground of exclusion clause 4.2.  We, therefore, find OP guilty of deficiency in service and direct OP to pay Rs.1,49,488/- (19,488 + 1,30,000) with 9% interest from date of claim to realization  We, also award Rs.30,000/- as compensation for harassment, mental agony inconveniences caused inclusive of litigation expenses.

        Order to be complied within 30 days.  File consigned to Record Room.

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

 

        Pronounced in open Court on 07.04.2015.

 

 

 

(C.K.CHATURVEDI)

PRESIDENT

 

 

 

(S.R. CHAUDHARY)         (RITU GARODIA)

MEMBER                          MEMBER