Delhi

New Delhi

CC/450/2012

Yogesh Puri - Complainant(s)

Versus

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

26 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/450/12                                      Dated:

In the matter of:

Sh. Yogesh Puri,

244, Dharamkunj Aptts.,

Sector-9, Rohini, Delhi-110085

 

……..COMPLAINANT

      

VERSUS

Royal Sundaram Allinace Ins. Co. Ltd.,

1505- 6, 5^th Floor, Ambadeep Building,

14, K.G Marg, Delhi-110001                               

 

                                         ……. OPPOSITE PARTY

 

 

ORDER

President: C.K Chaturvedi

              

The complaint of deficiency on the part of OP is in respect of denial of cashless treatment for emergency condition required immediate surgery for removing Appendicitis, to relive him of acute pain in the stomach. He got admitted in Max Health Hospital on 03.02.10, at 22-23 hours. The doctors did not perform surgery as sanction for cashless treatment was not received from Royal Sundaram/TPA despite giving of all documents to OP. He suffered pain for 20 hours, and thus left with no choice except to look some other hospital as he had no upfront money. He was forced to take discharge. He shifted to Ganga Ram hospital. There his pain subsided, and the doctors gave conservative treatment, and the surgery was done 1 month later. It is alleged that cashless is part of double protecting insurance for such emergencies. The Ganga Ram Hospital informed him that Royal Sundaram Company was black listed by them due to no clearance of bills.

The OP in its reply admits all facts but has taken a plea that no claim is payable, if admission is for less than 24 hours, though it later made the payment of Rs.16,500/-.

We have considered the rival case and find that OP is simply obfuscating the matter by an untenable plea. The facts show that complainant required immediate surgery and waited in pain for 20 hours, awaiting sanction, and doctors did not perform surgery for want of no sanction. There is no plea of OP that information or doctors were not available. It is clear case of callous attitude of OP, and deficiency on its part to not to respond for 20 hours, forcing the complainant to look for other options. The clause relied by OP does not apply for emergency admission and cannot apply for cashless and applying only for subsequent claims submitted after discharge before 24 hours. To wait for cashless so long is to defeat the promise of cashless, when one needed it most.

We hold OP deficient in services and we award compensation of Rs.40,000/- for denying cashless, when most needed by complainant and suffered mental agony and suffering awaiting long in pain. We also award litigation expenses of Rs.10,000/- to the complainant.

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 26.11.2015.

 

 

(C.K.CHATURVEDI)

PRESIDENT

 

 (Ritu Garodia)

MEMBER