Delhi

New Delhi

CC/225/2014

Sh. Sunil Sachdeva - Complainant(s)

Versus

M/S. United India Insurance Company - Opp.Party(s)

28 Nov 2019

ORDER

 

 

                           CONSUMER DISPUTES REDRESSAL FORUM-VI

                                (DISTT. NEW DELHI),

                        ‘M’ BLOCK, 1^STFLOOR, VIKAS BHAWAN, I.P.ESTATE,

                                                                   NEW DELHI-110001

 

Case No.C.C.NO.225/2014                                                    Dated:

 

              In the matter of:

Sunil Sachdeva,

Flat No.G-9, Plot No.11,

Bandhu Vihar Apartments,

Sec.10, Dwarka, New Delhi-75.

                 ……..COMPLAINANT

VERSUS

1.    United India Insurance Co. Ltd.

            Regional Office No.1,

            Kanchanjunga  Building,

            Barakhamba Road,

            Connaught Place,  New Delhi-110001.

 

2.     New India Assurance Co. Ltd.,

Divisional Office No.311500,

R-71, Main Green Park, New Delhi.

Opposite Parties

                

ARUN KUMAR ARYA, PRESIDENT

ORDER

 

The complainant has filed the present complaint against the OPs under section 12 of Consumer Protection Act, 1986.  The gist of the complaint is that OP-1  issued a staff mediclaim policy which covers all employees working with OP-2 Co. including the complainant for a sum insured of Rs.5,00,000/- which was renewed from time to time but OP-1 has neither issued any policy nor any policy details or its terms and conditions were ever provided to any employee of the company.  The complainant was a patient of progressive weight gain/hypertensive/diabetic etc.  and was on medication.  On 15.5.2013, the complainant was feeling uneasy, weakness, giddiness  so, he was taken to Max Hospital, where  various tests were done and he was diagnosed as patient of MORBID OBESITY.  Thereafter, the complainant was admitted in the said Hospital and as per the advise of doctor, immediately his gastric bypass surgery was done to save his life  and he was discharged on 20.5.2013.   The complainant spent  a sum of Rs.4,14,185/-  for his treatment.  An intimation was given to OP-1 through OP-2 and the OPs were requested to register the claim and to authorize the hospital for the claim expenses of the complainant.    After discharge from hospital, complainant lodged his  claim with OP-1 through OP-2 for reimbursement of Rs.4,14,185/- along with  all the original bills/copies and discharge certificate.  But OP-1 did not settle the claim of the complainant, moreover, OP-2  verbally informed him that no amount is payable against the above claim as the policy does not cover the disease.   Non-settlement of the claim  of the complainant is a clear case of deficiency in service, as per CP Act. Complainant, therefore, approached this Forum for redressal of his grievance.

2.     Notice of the complaint was sent to both the OPs. None appeared on behalf of OP-2, therefore, it was ordered to be proceeded with ex-parte vide order dt.  10.3.2015 by our  predecessor bench.  

3.     Complaint has been contested by the OP-1.  In its written statement, OP-1 has stated that if any dispute under Staff Mediclaim Policies are to be resolved by the Co., Co. itself  process the claims of staff, since  the  present claim was processed and paid by them i.e. M/s New India Assurance Co. Ltd.  Therefore, involvement of OP-1 is nil.  It is stated that OP-2 only provide the lumsum claims figure to OP-1 periodically for accounting purpose of the claims.  It is further stated that OP-1 tried to get claim file from the office of OP-2 officials and sent mails to OP-2 but OP-2 never gave any response in this regard and the complainant has no cause of action against OP-1.  Further prayed for dismissal of complaint.

4.     Complainant and OP-1 have filed their evidences by way of affidavits.

 

5.     We have heard argument advance at the Bar and have perused the record.

 

6.     Complainant has placed on record the copies of  bills and discharge summary of Max Hospital, copy of repudiation letter  issued by the OP in support of his case.

 

7.     From the un-rebutted testimony of the complaint and documents placed on record, we are convinced that the story put forth by the complainant is true. 

 

8.     In view of above discussion, we are of the considered view the repudiation of the claim by OP on the ground that no amount is payable against the above claim as the policy does not cover the disease is unjustified, and arbitrary, which amounts to deficiency in services on the part of OP-2. We therefore hold, OP-2 guilty of deficiency in services and direct it as under:-

i).  Pay to the complainant a sum of Rs.4,14,185/- along with interest @  9% p.a. from the date of institution of this complaint i.e.  25.03.2014  till its realization.

ii)   Pay to the complainant a sum of Rs.10,000/- as compensation towards harassment, mental agony and pain which will also include the cost of litigation.

 

 

A copy each of this order each be sent to both parties free of cost by post. Orders be also sent to www.confonet.nic.in. File be consigned to record room.

Pronounced in open Forum on 28/11/2019.

 

                                                        (ARUN KUMAR ARYA)

                                                                PRESIDENT

        (NIPUR CHANDNA)                                           (H M VYAS)

             MEMBER                                                         MEMBER