Delhi

New Delhi

CC/156/2008

Vineet Gupta & Anr. - Complainant(s)

Versus

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

09 Jun 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/156/08                        Dated:

In the matter of:

1. Sh. Vineet Gupta

S/o Sh. Hari Kishan Gupta

2. Smt. Anshika Gupta,

W/o Sh. Vineet Gupta

Both R/o: F-31, 2^nd Floor,

Jawahar Park, Devli Road,

Khan Pur, Delhi-110062

……..COMPLAINANTS

       

VERSUS

 

1. The Principal Officer,

M/s. Royal Sundram Alliance Insurance Co. Ltd., Having its registered office at:

21, Patullos Road, Chennai-600002

Also at:

1. Signature Towers, 9^th Floor,

        Tower-2, South City-1,

        NH-8, Gurgaon-122001

 

2. 1505, 1506, 15^th FL,

        Ambadeep Building, 14, K.G Marg,

        New Delhi-110001

 

2. The Principal officer,

Bajaj Capital nsurance Broking Ltd.,

GF, 97, Nehru Place, New Delhi-110001

 

3. The Principal Officer,

M/s. Medicare TPA Services (I) Pvt. Ltd.,

6, Bishop Lefroy road, Kolkata-700020

 

                                         ……..OPPOSITE PARTIES

 

ORDER

Member: S.R Chaudhary

 

The Complainant had taken a health insurance policy from OP1 on 22.06.06 covering the period 19.07.06 to 18.07.07 as per Exh.CW1/1 for self & wife as per Exh.CW1/2. Later it was further renewed as per Exh.CW1/3. Suddenly complainant’s wife felt pain in abdomen on 02/09 & 03/09/07 intervening night. She was admitted as per advice of Doctor in Akash Hospital immediately and it was diagnosed by Doctor that 12 MM sixe stone was in gladder as per Exh.CW1/4. Complainant immediately sent intimation to be OP for authorization of cashless facilities but it was declined by FAX dated 04.09.07 which is reproduced as under:-

“Such big, multiple stones are likely to develop within 14 months of policy, cashless cannot be improved in this case as pre-existing nature of the disease cannot be ruled out, hence a cashless request stands not approved but OP further also advised in the same letter as under:-,

            “However, the denial cashless facility does not restrict you to submit your formal claim along with all relevant documents after discharge for arriving at a logical conclusion in respect of your claim.”

  Keeping in view OP’s opinion, complainant filed the claim to OP after discharged from hospital on 06.09.09 and total hospital expenses was incurred Rs.35,262/- as per Exh.CW1/6 but it was repudiated on same ground again. While evaluating W.S and evidence of OP1 and OP2, OP2 has explained inability in Para4 of evidence that OP who acted as an agent who has not only sole responsibility to transmit. As per evidence of OP1 there is no dispute over policy but disputed on claim under plea that the problem of abdomen was prior before inception of policy but OP neither furnished any doctor’s observation nor any exclusion clause of stone with evidence except to mention in Para3 & Exh.R3 but R3 is not enclosed with evidence except imagination & speculative statement furnished in Para7 as well to deny the claim.

Thus, it appears very clearly that OP deliberately repudiated the claim without supporting any evidence which is clear case of breach of contract/unfair trade practices on the part of OP who knowingly brought the complainant into litigation for justice.

Keeping in view, OP is directed to refund Rs.35,262/- along with 9% interest from the date of discharge till realization. We also award Rs.25,000/- as harassment & litigation as the complainant has been unnecessarily suffering from 2008 till date.

The order shall be complied 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 09.06.2015.

 

 

 

(C.K.CHATURVEDI)

PRESIDENT

 

 

(S.R. CHAUDHARY)

MEMBER