DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, NORTH-WEST,

GOVT. OF NCT OF DELHI

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

CC No: 859/2016

D.No._________________                            Dated: ____________________

IN THE MATTER OF:

Smt. ANITA SEHGAL,

W/o LATE SH. RAJPAL SEHGAL,

R/o 5A, NAV SENA APARTMENT,

9 WEST ENCLAVE,PITAM PURA, DELHI-110034.… COMPLAINANT

Versus

NATIONAL INSURANCE CO. LTD.,

DP BLOCK 2^ND& 3^RD FLOOR (LSC),

PITAM PURA, DELHI-110088.                                    … OPPOSITE PARTY

CORAM :SH. M.K. GUPTA, PRESIDENT

                SH. BARIQ AHMED, MEMBER

      MS. USHA KHANNA, MEMBER

                                                            Date of Institution: 22.08.2016

Date of decision: 12.02.2018

SH. M.K. GUPTA, PRESIDENT

ORDER

1.       The complainant has filed the present complaint against the OP under the Consumer Protection Act, 1986 thereby alleging that the complainant and her husband took a health policy vide policy bearing no. 360700/48/16/8500000789 known as Parivar Mediclaim policy for the period from 01.05.2016 to 30.04.2017 for a sum of Rs.2,50,000/- from the OP and paid Rs.12,497/- as the premium. The complainant further alleged that the policy

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          commenced from 2004 and continuously continued till-2017 and the complainant renewed the policy time and again and paid the premium. The complainant further alleged that the complainant’s husband namely Late Sh. Rajpal Sehgal was hospitalized at Maharaja Agarsen Hospital, Delhi on 16.06.2016 due to infection in chest. The complainant further alleged that the TPA of OP continued rejecting the cashless treatment claim for 7 days and the complainant visited the office of TPA and thereafter released the amount of Rs.1,00,000/- in 2 installments to the hospital and refused to release the balance amount. The hospital bill was of Rs.3,11,050/- and besides this amount the complainant has spent an amount of Rs.14,716/- of purchase of medicines and the OP failed to release the said amount on the ground that full amount as per policy has been realized vide letter dated 29.06.2016. The complainant further alleged that her husband died on 29.06.2016 and the OP refused to release the amount and the complainant paid the hospital bill after arranging the money/amount from her relatives. The complainant further alleged that the Mediclaim policy was of Rs.2,50,000/- of which OP paid an amount of Rs.1,00,000/- and OP has wrongfully rejected the claim and has been harassing the complainant as per general practice of the insurance company and OP is accordingly guilty of deficiency in service.  

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2.       On these allegations the complainant has filed the complaint praying for direction to OP to pay Rs.1,50,000/- being the balance amount and has also sought compensation for causing harassment etc. and has also sought litigation cost.

3.       Earlier the OP has been contesting the case and Counsel for OP filed memo of appearance on 24.10.2016& sought time to file written statement and the matter was adjournedfor 16.01.2017. On which date i.e. on 16.01.2017, Counsel for OP further sought time to file written statement and request was allowed subject to imposition of cost of Rs.500/- and the matter was adjourned for 06.04.2017. Againon 06.04.2017, proxy counsel for OP appeared and further sought time to file written statement and request was allowed with further cost of Rs.1,000/- and the matter was adjournedfor 07.07.2017 and last opportunity was given to OP to file written statement. However,on 07.07.2017, none for OP appeared and OP was proceeded ex-parte vide order dated 07.07.2017.

4.       In order to prove her case the complainant filed her affidavit in evidence and also filed written arguments. The complainant also placed on record copy of Parivar Mediclaim policy bearing no. 360700/48/16/8500000789 for the period from 01.05.2016 to 30.04.2017, copy of final receipt no. 400341 dated 29.06.2016 of

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          Rs.1,26,050/- issued by Maharaja Agarsen Hospital, Delhi, copies of advance receipts no. 396006 dated 16.06.2016 & receipt no. 399977 dated 28.06.2016 issued by Maharaja Agarsen Hospital regarding deposit of amount of Rs.25,000/- & Rs.60,000/- respectively, copies of retail invoice no. 9259 dated 26.06.2016 of Rs.1,894/- issued by Shri Balaji Medicos, Punjabi Bagh, Delhi, retail invoice no. 7837 dated 26.06.2016 of Rs.3,204/-, no. 7828 dated 26.06.2016 of Rs.403/-, receipt no. 7918 dated 27.06.2016 of Rs.2,516/-, receipt no. 7861 dated 27.06.2016 of Rs.3,336/-&receipt no. 8055 dated 28.06.2016 of Rs.3,363/- issued by Ladli Jee 98.4 chemist, Punjabi Bagh, Delhi, copy of denial of additional authorization letter issued by OP, copy of authorization letter-2 regarding release of Rs.1,00,000/- and copy of death summary of Sh. Rajpal Sehgal issued by Maharaj Agarsen Hospital, Punjabi Bagh, Delhi and death certificate of Sh. Rajpal Sehgal.

5.       This forum has considered the case of the complainant in the light of evidence and documents placed on record by the complainant.

6.       As already discussed, the case of the complainant has remained consistent throughout, unrebutted and unchallenged. There is nothing no record to disbelieve the case of the complainant. Moreover, OP has not bothered to contest this case before this Forum despite receiving the notice. It accordingly seems to us that

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          the OP has no defence at all and has unlawfully repudiated the claim of the complainant. Thus, OP is held guilty of deficiency in service.

7.       Thus, holding guilty for the same, we direct the OP to

ii) To pay to the complainant an amount of Rs.50,000/- as compensation for harassment andmental agony suffered which includes cost of litigation.

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

9.     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 12^thday of February, 2018.

BARIQ AHMED                         USHA KHANNA                         M.K. GUPTA

   (MEMBER)                                 (MEMBER)          (PRESIDENT)

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