Delhi

New Delhi

CC/202/2010

Meghna Mehta Hazarika - Complainant(s)

Versus

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

27 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/202/10                                      Dated:

In the matter of:

1. Ms. Meghna Mehta Hazarika,

Through Power of Attorney Holder,

Mr. Sanjoy Hazarika,

D/o Mr. Sanjoy Hazarika,

R/o B-14, Press Enclave, Saket,

New Delhi-110017

 

2. Mr. Sanjoy Hazarika,

S/o late C.N Hazarika,

R/o B-14, Press Enclave, Saket,

New Delhi-110017

 

……..COMPLAINANTS

      

VERSUS

 

The Manager (Claims),

Royal Sundaram Alliance Insurance Co. Ltd.,

Sundaram Towers, 45, 46 Whites Road,

Chennai-600014

Having its Delhi Office at

Royal Sundaram Alliance Insurance Co. Ltd.,

1505-150, 15^th Floor, Ambadeep Building,

14, K.G Marg, Connaught Place, Delhi-110001

 

                                         ……. OPPOSITE PARTY

 

 

 

ORDER

President: C.K Chaturvedi

              

The complaint pertains to deficiency in service by arbitrary repudiation of claim of reimbursement under two hospitalizations policy no.HCSTCB0002 and HLSTCB0024 issued by OP vide Annexure P1. The claimants are legal heirs of late Mrs. Minal Hazazrika. They along with their deceased mother was beneficiary in the above policies. The deceased mother was a patient of High Blood Pressure and has so indicated in the Proposal Form taking the policy. The policies were in force continuously for 4 years, till 02.04.09 when she died in Ganga Ram hospital. The facts show that she with claimants were in Guwahati on 14.01.09, when she suffered a stroke, and hospitalized there in GNRC Institute of Neurological Sciences, and was diagnosed with right giant internal carotid artery aneurysm right pica aneurysm with hydrophalus and was shifted to Ganga Ram Hospital, for treatment from 20.01.09 till 23.03.09 vide discharge summary Annexure R3. From there she was shifted to East West Medical Centre, and request for cashless for room rent of Rs.1,90,000/- was denied by OP on 02.04.09, on the grounds of BP for lost 9 years, as pre-existing and complication of pre-existing disease. She was shift to Ganga Ram hospital, due to deteriorating conditional and on 02.04.09 died there.

This complaint is in respect for stay in East West Medical Centre from 23.03.09 till death on 02.04.09 costing Rs.1,90,000/- for room charges.  It is stated that expenses for the treatment in Ganga Ram Hospital have been paid by Alankit TPA of OP, but room charges are denied by TPA of OP.

The OP in its reply has reiterated the grounds of repudiation stating it to be a case of pre-existing disease and complication of pre-existing disease. It has not denied the fact that deceased had already disclosed BP, before taking hospitalization policy and the fact that it was already 4 years of policy, which covered even pre-existing disease, if any.

The policy of law and rules of Insurance Regulator are in well settled, and in this case, OP could not have denied cashless as well as reimbursement on the grounds of pre-existing diseases, particularly when the other TPA had already returned the expenses for treatment at Ganga Ram Hospital. This charges for room rent at East West Medical Centre, cannot be denied by other TPA of same Insurance Company.

We find that OP has acted in violation of condition of policy and law, and Insurance Regulations of policy to cover all pre-existing after 4 years. We find it guilty of deficiency in services and direct it to pay Rs.2 lakhs for amount paid in hospital and Rs.50,000/- for compensation and Rs.20,000/- 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 27.11.2015.

 

 

 

(C.K.CHATURVEDI)

PRESIDENT

 

 

 (Ritu Garodia)

MEMBER