Delhi

New Delhi

CC/121/2014

Mrs. Sabina Avasthy - Complainant(s)

Versus

M/S. United India 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/121/14                                      Dated:

In the matter of:

Mrs. Sabina Avasthy & her father Mr. O.P Anand,

411, Mavilla Apartments,

Mayur Vihar Phase-I, Delhi-91

……..COMPLAINANT

       

VERSUS

1. M/s. United India Insurance Co. Ltd.,

Regional Office 1, Kanchanjunga Building, K.G Marg, Connaught Place, New Delhi-110001

 

2. The Managing Director,

M/s. E-Meditik (TPA) Service Pvt. Ltd.,

Head office, plot no.577, Udyog Vihar,

Phase 5, Gurgaon-122016

                                         ……. OPPOSITE PARTY

 

ORDER

President: C.K Chaturvedi

               

The case of the complainant against OP insurance company highlights total mala fide attitude of OP, in dealing with a just claim, and this forced the filing of this complaint for redressal and compensation.

It is alleged that complainants had a super top up insurance policy from OP for the period 01.04.10 to 31.03.11. This was in continuation of earlier policy from New India Assurance Company since 2003, without any break and without claiming any no claim bonus till date. The policy of OP provided that it would cover any pre-existing disease after 48 months, inclusive of any earlier policy period in continuation.

It is alleged that Mrs. Prabha Anand, nsured complainant had a knee problem for which he had to take treatment (Para4 to 6 of Complaint) at a cost of Rs.5 lakhs, when the earlier company policy was in force. The earlier insurance company paid Rs.4,21,418/- out of this expenses by way of reimbursement. The balance of Rs.1,13,686/- was demanded from the current policy insurer of OP insurance company. All necessary documentation were given as desired, and even were available with the first insurance co., which had already paid substantial amount, yet, OP demanded more and more documents, and falsely closed the claim as ‘No claim’ based on an anti-dated letter, though delivered late.

It is alleged that by inadvertence OP sent a copy of internal email between OP’s offices stating why this policy was insured when complainant’s father earlier had a disease. It is alleged that OP later on went on inventing more and more grounds to reject the claim, as mentioned in detail in the complaint.

The OP filed a reply reiterating the exclusion clause, but failed to file any evidence and its defense was struck off.

After considering the submission of complaint evidence & averments and supporting material, it is clear that OP is clearly acting arbitrarily with mala fide intention to defeat the just claim. The OP has clearly misdirected itself by treating claim as a claim for pre-existing disease rather than treating it as a claim for remaining balance of treatment expenses. It has taken numerous stands as desired in the complaint to deny the claim. OP is under obligation to pay the balance of earlier treatment. We hold OP liable for deficiency and direct it to reimburse the outstanding sum of Rs.1,13,686/- with interest of 9% from date of closing of case as ‘no claim’ and pay Rs.40,000/- for harassment, deficiency and 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 ……………….

 

 

(C.K.CHATURVEDI)

PRESIDENT

 

 (Ritu Garodia)

MEMBER