Delhi

New Delhi

CC/369/2010

Kalika Chaudhary - Complainant(s)

Versus

M/S. Royal Sundaram Alliance Insurance Company Ltd. - Opp.Party(s)

28 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/369/10                            Dated:

In the matter of:

Mrs. Kalika Chaudhary,

W/o late Sh. Harish Chaudhary,

R/o Hari Om, KD-13, Kavi Nagar,

Ghaziabad-201002

……..COMPLAINANT

       

VERSUS

1. Reliance General Insurance Co. Ltd.,

        202-210, 2^nd FL, Mercantile House,

        15, K.G Marg, New Delhi-110001

 

2. Paraamount Health Services Pvt. Ltd.,

        F-90/12, Near ESI Hospital,

        Ohkla Industrial Area, Phase I, Delhi-110020

 

3. Richard Strauss Insurance Broking Pvt. Ltd.,

        III-N/28, Nehru Nagar, Ambedkar Raod,

        Ghaziabad-201001

                         ………. OPPOSITE PARTIES

 

ORDER

President:  C.K Chaturvedi

 

        The complainant was a beneficiary of a cashless medi claim policy from OP, from 09.06.07 to 08.06.09, and on 15.04.08, she was admitted in Artemis Health Hospital, for treatment of Achlasia Cardia Cirrhotic liver and was discharged on 24.04.08. She was investigated up to 18.04.08. Suring her admission she requested for cashless which was refused, as OP could not be sure of treatment. On discharge, she presented a claim of Rs.2,08,275/- towards treatment. This claim was denied and repudiated on 05.03.09 on ground that it was a case of pre-existing disease, as an endoscopy was done in 2007, for difficulty in swallowing, and therefore the disease would not have developed suddenly and must be developing over a period of time.

        The complainant alleged this repudiation as totally false & frivolous, and claim compensation for mental agony, deficiency and treatment expenses.

        The OP1 in its reply has reiterated the grounds of repudiation and OP2 TPA was proceeded exparte.

        We have considered the evidence of the parties and perused the record and heard the submission. The discharge summary of the hospital is on record and is conclusive of treatment, diagnosis and liability etc. The discharge summary stated that she was diagnosed for acute gastric                         dilatation with gastroparesis and endoscopic decompression of stomach was done on 21.04.08 and states that she was admitted in emergency and managed as described.

        We find that the OP1 has inverted itself a disease and diagnosis which does not match with hospital discharge summary & treatment. OP1 has indulged in conjectures & speculation only on the basis of a single endoscopic examination in 2007, which is neither here nor there and is a mala fide denial of just claim.

        We hold OP guilty of deficiency and direct OP1 to pay Rs.2,08,275/- with interest of 9% from date of 3 months after claim filing with OP1 and we award a compensation of Rs.50,000/- for harassment, deficiency and mental agony and Rs.20,000/- for 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 28.04.2015.

 

 

(C.K.CHATURVEDI)

PRESIDENT

 

(S.R. CHAUDHARY)                 (Ritu Garodia)

MEMBER                                  MEMBER