Delhi

East Delhi

CC/88/2017

MANOJ YADAV - Complainant(s)

Versus

N.I.C. - Opp.Party(s)

17 May 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. NO. 88/17

 

Dr. Manoj Kumar Yadav

S/o Shri S.S. Yadav

R/o C-29/Y-4, 1^st Floor

Pocket-C, Dilshad Garden

Delhi – 110 095                                                          ….Complainant

Vs.    

 

1. National Insurance Co. Ltd..

Through its Manager

DO XXVIII, 11^th Floor,

Scope Minar (N)

Delhi – 110 092

         

2. East West Assist Pvt. Ltd. (TPA)

404 & 602, DLF Place Saket

4^th Floor, Mall Office Block

District Centre Saket

New Delhi – 110 017                                                      …Opponents

 

 

Date of Institution: 28.02.2017

Judgement Reserved on: 11.09.2019

Judgement Passed on: 16.09.2019

 

CORUM:

Sh. Sukhdev Singh (President)

Dr. P.N. Tiwari (Member)

Ms. Harpreet Kaur Charya (Member)

 

Order By: Sh. Sukhdev Singh (President)

 

JUDGEMENT

           This complaint has been filed by Dr. Manoj Kumar Yadav against  M/s. National Insurance Co. Ltd. (OP-1) and M/s. East West Assist Pvt. Ltd. (OP-2) under Section 12 of the Consumer Protection Act, 1986 with allegations of unfair trade practice and deficiency in service. 

2.        The facts in brief are that the complainant Dr. Manoj Kumar Yadav was having a cashless mediclaim policy no. 371201/148/16/8500000271 for a period from 03.08.2016 to 02.08.2017 with a cover of Rs. 2,00,000/-.  On 29.08.2016, the complainant slipped in the home and sustained comminuted fracture proximal humerus left side (arm).  He was having severe pain and swelling in left arm.  He was unable to perform his normal activities due to the said injury. 

On 29.08.2016, he was admitted in Max Super Speciality Hospital, IP Extension, Patparganj with IP no. 253181 and registration no. NHWZ 2011984.  He was examined by Dr. Anil Arora who diagnosed as swelling, abnormal mobility with bony crepitus, tenderness over left arm and there was no distal neurovascular deficit and advised surgery.  Open reduction and biological fixator with 10hole PHILOS plate was done and U-slab was applied.  He was discharged on 02.09.2016 and advised rest from 02.09.2016 to 05.10.2016.  He was also advised physiotherapy as well as medicines. 

He intimated to the hospital authorities as well as the TPA of National Insurance Company Ltd. (OP-1) and requested for cashless facility.  He was denied cashless services with the assurance that the complainant can take reimburse after discharge from hospital.  He paid a sum of Rs. 2,02,653/- to the hospital and Rs. 1,089/- towards purchase of medicine.  Thus, the complainant have incurred a total sum of                  Rs. 2,03,742/- towards his treatment.  The TPA duly received all the documents pertaining to treatment from the complainant. 

The complainant filed his claim vide claim no. 387695 which was not approved till date after lapse of almost 110 days.  By not giving cashless facility, National Insurance Company have committed deficiency in services.  A legal notice of dated 28.12.2016  served upon OP to pay a sum of Rs. 2,00,000/- alongwith interest @ 18% p.a.  Despite receiving the legal notice, they have neither approached the complainant for payment nor repudiated the claim.  Thus, the complainant have stated that he was entitled for a sum of Rs. 2,00,000/- alongwith interest @ 18% p.a. from the date of filing as well as of Rs. 1,00,000/- on account of misrepresentation, mental harassment, financial loss and loss of income.   Hence, he has prayed for directions to OP to pay an amount of Rs. 2,00,000/- alongwith interest @ 18% p.a. from the date of claim i.e. 29.08.2016; compensation of Rs. 1,00,000/- towards mental agony and harassment and Rs. 50,000/- towards cost of litigation. 

3.        In reply filed on behalf of M/s. National Insurance Co. Ltd. (OP-1) and M/s. East West Assist Pvt. Ltd. (OP-2), they have stated that as per the investigation report given by OP-2, the complainant met with an accident at Haridwar, 12 days back and he did not disclose this neither to the hospital nor to the insurance company.  He has given mis-representation of facts.  They have stated that the complainant was not entitled for the relief claimed.  They have denied other facts also. 

4.        Complainant have filed rejoinder to the WS of OP-1 & 2, wherein he has controverted the pleas taken in the WS and reasserted his pleas.

5.        In support of its case, the complainant have examined himself.  He has deposed on affidavit.  He has narrated the facts which have been  stated in the complaint. 

           In defence, OP-1 & 2 have examined Shri Rajneesh Kumar, Administrative Officer in National Insurance Company (OP-1), who have also deposed on oath.   He has also narrated the facts which have been stated in the WS. 

6.        We have heard Ld. Counsel for the parties and have perused the material placed on record.  The only argument which has been advanced on behalf of National Insurance Company (OP-1) has been that the complainant have met with an accident at Haridwar which he did not disclose to the insurance company as well as to the hospital.  There was mis-representation of facts.

           On the other hand, Ld., Counsel for the complainant have argued that National Insurance Company (OP-1) did not put any document to show that the complainant have met with an accident at Haridwar.

           To appreciate the arguments of Ld. Counsel for the parties, a look has to be made to the testimony of complainant Dr. Manoj Kumar Yadav and Shri Rajneesh Kumar, Administrative Office of National Insurance Company (OP-1), it is noticed that he has only taken this plea in his testimony that investigation report given by TPA (OP-2) was that the complainant have met with an accident at Haridwar, 12 days back and he did not disclose this fact to the insurance company as well as to the hospital.  Though, they have taken this plea, but there is nothing on record to substantiate this fact.  In the absence of any evidence, this plea of National Insurance Company (OP-1) cannot be accepted.  Therefore, this argument of Ld. Counsel for National Insurance Company (OP-1) goes.

           Coming to the testimony of Dr. Manoj Kumar Yadav and the documents placed on record, it is evident that the complainant was having policy of National Insurance Company (OP-1) for a period from 03.08.2016 to 02.08.2017.  He has taken the treatment during the subsistence of the policy.  He has submitted the claim with the insurance company as is evident from the form of M/s. East West Assist Pvt. Ltd. (OP-2) which shows the claim and the documents received by the TPA (OP-2).  On this form, claim no. has been stated as 387695.  These documents have been received by M/s. East West Assist Pvt. Ltd. (OP-2) on 06.09.2016.  Having received these documents and registered the claim showing claim no. 387695 and not disposing the claim within the stipulated period, certainly, it amounts to deficiency on the part of insurance company. 

The fact that insurance company have not processed and disposed of the claim of the complainant, certainly, the complainant have suffered mental pain and suffering for which he has to be compensated.

In view of the above, we order that M/s. National Insurance Company (OP-1) shall dispose of the claim of the complainant as per terms of the policy within a period of 60 days.  We further order that the complainant be paid a sum of Rs. 20,000/- on account of mental pain and suffering.  If the order is not complied within the stipulated period, the complainant shall be entitled 9% interest on the amount which will be passed by the National Insurance Company (OP-1) as per terms and conditions of the policy, after a period of 60 days.  The compensation amount of Rs. 20,000/- will also carry 9% interest from the date of order.

Before parting with, it would not be out of place to mention that the insurance company who has taken the plea that the accident has happened at Haridwar, have failed to place on record the investigation report given by M/s. East West Assist Pvt. Ltd. (OP-2) which have helped the complainant Dr. Manoj Kumar Yadav for getting the deficiency proved.  If the National Insurance Company (OP-1) would have placed this document on record, the onus would have been on the complainant Dr. Manoj Kumar Yadav to negate that fact.  The investigation report being a vital document for getting the claim accepted or repudiated withholding the same for the reasons best known to the department amounts to negligence on the part of its officials.  M/s. National Insurance Company (OP-1) is directed to instruct their officials to take care of such documents in order to avoid such lapses. 

Copy of the order be supplied to the parties as per rules.

           File be consigned to Record Room.

 

 

 

(HARPREET KAUR CHARYA)                                        (SUKHDEV SINGH)

              Member                                                                     President