DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, NORTH-WEST

GOVT. OF NCT OF DELHI

CSC-BLOCK-C, POCKET-C, SHALIMAR BAGH, DELHI-110088.

CC No.27/2018

D.No._______________________                            Dated: _______________

IN THE MATTER OF:

SUBHASH CHAND KASERA,

S/o LATE SH. HARI CHAND KASERA,

R/o K-5, MODEL TOWN, DELHI-110009.   … COMPLAINANT

Versus

1. NATIONAL INSURANCE CO. LTD.,

    THROUGH THE BRANCH MANAGER,

    DIVISION OFFICE-28, SCOPE MINAR,

    CORE-2, 11^th FLOOR,

    NORTH TOWER DISTRICT CENTRE,

    LAXMI NAGAR, DELHI-110092.

2. NARANG EYE INSTITUTE,

    THROUGH THE MEDICAL SUPERINTENDENT),

    B-8, DERAWAL NAGAR, DELHI-110009.          …OPPOSITE PARTY (ies)

CORAM:SH. M.K. GUPTA, PRESIDENT

               SH. BARIQ AHMED, MEMBER

                                                            Date of Institution: 08.01.2018

Date of decision: 26.11.2019

SH. M.K. GUPTA, PRESIDENT

ORDER

1.       The complainant has filed the present complaint against OPs under Section 12 of the Consumer Protection Act, 1986 therebyalleging

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          thatthe complainant has purchased a Mediclaim Insurance Policy bearing No. 361700/48/15/8500002150 for a sum of Rs.5,00,000/- for the said policy from OP-1 and the policy commencing w.e.f. 11.09.2015 to 10.09.2016 (mid-night) and the insured persons against the policy are himself and his wife Smt. Nirmal Kasera. The complainant further alleged that the complainant was facing some cataract problem in eye as such got admitted in OP-2 i.e. Narang Eye Institute, Delhi on 11.01.2016 for treatment/cataract surgery and after treatment/surgery the complainant was discharged on same day i.e. 11.01.2016 and intimation of admission was sent to OP-1 on the same day. The complainant further alleged that the total expenditure paid by the complainant on treatment is Rs.75,000/- and the claim and inspite of taking Mediclaim policy, the complainant was compelled by OP-1 to get the treatment by arranging the money/amount from different sources with great difficulty and the complainant applied OP-1 for releasing the claim but there is no proper response given by OP-1 and lastly OP-1 only passed Rs.34,000/- against the claim amount of Rs.75,000/-. Thereafter, OP-1 is not releasing the total claim on one pretext and other and the complainant supplied all relevant copies of the documents to OP-1 but the officials of OP-1 are not giving response in this matter nor releasing the total claim and in this regard, the complainant approached OP-1 uncounted times but

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          there is no proper response in this matter by them nor they are releasing the total claim and the action of OP in refusing the legal claim amounts to deficiency in service on the part of OP. 

2.       On these allegations the complainant has filed the complaintpraying for direction toOP-1 to release the balance claim amounting i.e. Rs.41,000/- alongwith interest @ 24% p.a. till the realization of amount as well as compensation of Rs.1,00,000/- for causing mental agony and harassment and also sought of Rs.11,000/- as  costs of proceeding.

3.       OP-1 has been contesting the complaint and filed reply. In the reply, OP-1 submitted that the complaint is not maintainable and is liable to be dismissed. OP-1 further submitted that the complainant has taken a Mediclaim policy from OPs bearing no.361700/48/15/ 85000002150 for the period from 11.09.2015 to 10.09.2016 and the policy was issued subject to the terms & conditions. OP-1 further submitted that the complainant had taken treatment for cataract at OP-2 on 08.01.2016 and has submitted a claim of Rs.75,000/- i.e. Rs.55,000/- towards cost of lens and Rs.20,000/- towards surgeon fees and OPs have approved for payment of claim of Rs.34,000/- i.e. Rs.14,000/- towards cost of unifocal lens and Rs.20,000/- towards surgeon fees and instead of accepting the payment the complainant had chosen to file a frivolous litigation.

4.       Whereas none for OP-2 appeared despite service and was proceeded ex-parte vide order dated 30.10.2018.

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5.       The complainant filed rejoinder and denied the submissions of the OP-1 and furthersubmitted that OP-1 has taken a misleading plea.

6.       In order to prove his case, the complainant filed his affidavit in evidence and also filed written arguments. The complainant also placed on record copy of insurance policy no. 361700/48/15/ 8500002150 issued by OP-1, copy of intimation of claim to OP-1 through mail dated 11.01.2016, copy of Cataract Discharge Summary issued by OP-2, copy of final bill dated 11.01.2016 of Rs.75,000/- issued by OP-2, copy of IPD receipt dated 11.01.2016 issued by OP-2, copy of retail invoice no.109713 dated 11.01.2016 of Rs.55,000/- issued by Medioptics, New Delhi, copy of claim form/letter, copy of certificate dated 10.02.2016 issued by OP-2 to the effect that the complainant was operated for Cataract surgery with extended Focus Lens the total invoice of procedure is Rs.75,000/- including cost of lens of Rs.55,000/- and surgeon fee Rs.20,000/- and there is no bifurcation of surgeon fees and copies of Claim Status that claim is passed by OP-1 for Rs.34,000/-.

7.       On the other hand, Sh. Sudhir Gulati, Assistant Manager of OP-1 filed his affidavit in evidence. OP-1 also filed copy of terms & conditions of insurance company. OP-1 has also filed written arguments.

8.       This forum has considered the case of the complainant as well asOP-1 in the light of evidence and documents placed on record by the parties. The case of the complainant has remained consistent

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          and there is nothing on record to disbelieve the case of the complainant. The documents and evidence of the parties shows that the complainant was hospitalized in Narang Eye Institute for the treatment/surgery of eye disease and under gone Cataract surgery in the hospital of OP-2 on 11.01.2016. This fact is not disputed by OP-1 and it is not explained by OP-1 as to on what basis claim of Rs.34,000/- instead of Rs.75,000/- has been passed and in these circumstances, this forum is of opinion that OP-1 was not justifiedin denying the full claim of the complainant. Thus, OP-1 is held guilty of deficiency in service and unfair trade practice.

9.       Thus, holding guilty for the same, we direct OP-1 to: -

ii) To pay to the complainant an amount of Rs.25,000/- as compensation for harassment and mental agony.

10. The above amount shall be paid by OP-1 to the complainantwithin 30 days from the date of receiving copy of this order failing which OP-1 shall be liable to pay interest on the entire awarded amount @ 10% perannum from the date of receiving copy of this order till the date of payment. If OP-1 fails to comply with the order within 30

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         days from the date of receiving copy of this order, the complainant may approach this Forum u/s 25 of the Consumer Protection Act, 1986.

11. Let a copy of this order be sent to each party free of cost as per regulation 21 of the Consumer Protection Regulations, 2005. Thereafter file be consigned to record room.

Announced on this 26^th day of November, 2019.

BARIQ AHMED                                                       M.K. GUPTA

   (MEMBER)                                                       (PRESIDENT)

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