Delhi

New Delhi

CC/1085/2010

S.M. Aamir - Complainant(s)

Versus

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

04 Aug 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/1085/10                           Dated:

In the matter of:

Sh. S.M Aamir,

S/o Sh. S.A.M Raja,

R/o A-3450, Street No.7,

S.G.M Nagar, NIT, Faridabad

……..COMPLAINANT

       

VERSUS

1. Reliance General Insurance Co. Ltd.,

        570, Nai Gaum Cross Road,

        Next to Royal Indus Trial Estate,

        Wadala (W), Mumbai-400031

Also at:

        202-21, Second Floor,

        Mercantile House, K.G Marg,

        New Delhi-110001

 

2. M/s. Medi Assist India Pvt. Ltd.,

Kailash Bhawan, East of Kailash, Delhi

                                         ……. OPPOSITE PARTIES

 

 

ORDER (Oral)

Date of Arguments: 04.08.2015

Member: Ritu Garodia

Present:    Both the Parties.

                Arguments heard.

We have heard the argument, perusal of the pleadings and affidavit placed by both parties.

The short facts are that Complainant purchased a medi claim policy bearing no.1305/282510417060 from 15.05.09 to 14.05.10 from OP2. Complainant was admitted on 20.10.09 as per discharge paper along with claim form annexed. Complainant filed a claim for hospital bills which are annexed.

OP repudiated the claim on the grounds of pre-existing disease under exclusion Clause 7. Terms and conditions annexed. The discharge summary reveals that complainant was admitted for Dyslidamia. Claim form contains statement of treating doctor, Dr. G.S Chabra, Senior Consultant, Respiratory Medicine, Escorts Hospital, who clearly states that present illness is not pre-existing and first symptom appeared ‘since two day’. Hospital bills for Rs.20,611/- are annexed and bills for medicines are for Rs.7,35/- (Rs.181/- + 408+ 146) are also placed on record. OP has relied on Clause 7 of execution clause states “Routine medical eye and ear and examinations, cost of spectacles, laser surgery, contact lenses or hearing aids, vaccination, issue of medical certificates and examination as to suitability for employment or travel. OP has not adduced any evidence of disease being pre-existing nor has rebutted the statement by treating doctor.

In the circumstances, OP is guilty of deficiency in repudiating the legitimate claim of insured in an arbitrary manner. OP is directed to settle the claim for Rs.20,611/- + Rs.7,53/- with interest @ 9% per annum from date of claim till payment. We also award Rs.10,000/- as compensation for harassment caused by insurance company which refuses to settle the valid claims after accepting full premium and promising to provide full health coverage to ordinary common man. We also award Rs.5,000/- for 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 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 04.08.2015.

 

 

 

(C.K.CHATURVEDI)

PRESIDENT

 

 

 (Ritu Garodia)

MEMBER