DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, NORTH-WEST

GOVT. OF NCT OF DELHI

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

CC No: 59/2017

D.No._______________________                            Dated: _______________

IN THE MATTER OF:

SATYA NARAYAN AGARWAL,

S/o SH. S.B.L. AGARWAL,

R/o 22, BANNU ENCLAVE, ROAD No.-42,

PITAM PURA, DELHI-110034.  … COMPLAINANT

Versus

1. NATIONAL INSURANCE CO. LTD.,

    (THROUGH ITS BRANCH MANAGER),

    201, HARSHA HOUSE, MILAN COMPLEX,

    KARAM PURA, NEW DELHI-110015.                                          

2. SHRI SHYAM NURSING HOME,

    (THROUGH MEDICAL SUPERINTENDENT),

    PKT-6, H. No.212, SECTOR-22,

    ROHINI, NEW DELHI-110086.                         …OPPOSITE PARTY(IES)

CORAM:SH. M.K. GUPTA, PRESIDENT

               SH. BARIQ AHMED, MEMBER

     MS. USHA KHANNA, MEMBER

                                                            Date of Institution: 16.01.2017

Date of decision: 04.11.2019

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 thatthe complainant has taken a Mediclaim Policy bearing no.360303/48/15/8500000431 from OP-1 and the sum insured was

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          Rs.3,00,000/- for the said policy and the insured period from06.05.2015 to 05.05.2016 (mid-night) and the insured person’s against the policy are Satya Narayan Agarwal (self), Smt. Anita Agarwal (wife) and Ritesh & Pratyaksh Agarwal sons of the complainant. The complainant further alleged that the wife of the complainant had severe pain in stomach, loose motion, fever on 19.03.2016 and got admitted in Shri Shyam Nursing Home i.e.OP-2 on 19.03.2016 & after treatment the hospital discharged the patient Smt. Anita Agarwal on 25.03.2016 and the total expenditure paid by the complainant on treatment is Rs.33,996/-. Thereafter, inspite of taking Mediclaim Policy, the complainant was compelled from different sources with great difficulty and the complainant applied/requested OP-1 for allowing/releasing the claim but no proper response given by OP-1. The complainant further alleged that OP-1 is not allowing/releasing the claim on one pretext and other and the complainant further alleged that the complainant supplied all relevant copies of the documents to OP-1 but the officials of OP-1 is not giving proper response in this matter nor releasing the claim and OP-1 repudiated the claim on false grounds. The complainant further alleged that the complainant approached OP-1 several times but there is no proper response in this matter by OP nor OP is releasing the claim and OP-1 failed to release the claim despite repeated requests of the complainant and the action

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          of the OP-1 in refusing the legal claim amounts to deficiency in service on the part of OP-1. 

2.       On these allegations the complainant has filed the complaintpraying for direction toOP-1 to give/release the claim amount i.e. Rs.33,996/- alongwith interest @ 24% p.a. till its realization 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.       OPs have been contesting the complaint and filed reply. In its reply OP-1 submitted that the complaint is not maintainable and is liable to be dismissed. OP-1 further submitted that it had issued to the complainant Mediclaim Insurance Policy bearing no. 360303/48/15 /850000431 and the policy was effective for the period from 06.05.2015 to 05.05.2016 (mid-night) and the insurance was granted subject to terms & conditions as stated in the policy and one of the conditions of the policy that the Nursing Home where the treatment is taken should have at least 15 beds and on investigation it was found that the said Nursing Home is registered for only nine beds and it was further that there was no Nursing staff and no doctor was available.

4.       Whereas OP-2 did not file its reply or Written Statement.

5.       The complainant filedrejoinder 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

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          evidence and also filed written arguments. The complainant also placed on record copy of insurance policy no. 360303/48/ 15/8500000431 for the period from 06.05.2015 to 05.05.2016(mid-night) issued by OP-1, copy of discharge summary issued by Shri Shyam Nursing Home, Kirari, Delhi, copies of Registration Certificates dated 15.10.2013, 04.08.2016, copy of receipt dated 03.04.2016 of Rs.33,996/-, copy of cash bill no.579 dated 25.03.2016 of Rs.10,150/- issued by OP-2, copies of receipt no.734 dated 19.03.2016 of Rs.4,000/- & no.742 dated 25.03.2016 of Rs.6,150/-, copies of receipt/bill no.15-16/7/170 dated 19.03.2016 of Rs.5,085/- and no.15-16/1/164 dated 18.03.2016 of Rs.450/- issued by Life Care Path Lab, copies of retail invoices dated 19.03.2016 of Rs.3,654/-, dated 20.03.2016 of Rs.2,847/-, dated 21.03.2016 of Rs.2,842/-, dated 22.03.2016 of Rs.2,812/-, dated 23.03.2016 of Rs.5,138/- and dated 25.03.2016 of Rs.1,018/- issued by Rai Traders for purchase of medicines, injections, syringes etc. having endorsement by OP-2 and copy of repudiation letter dated 12.05.2016 sent by OP-1 to the complainant.

7.       On the other hand, on behalf of OP-1 Ms. Shuchi, Branch Manager of OP-1 filed her affidavit in evidence. OP-1 also filed copy of Baroda Health Policy. OP-1 has also filed written arguments.

8.       However, on behalf of OP-2 Dr. Rahul Gautamof OP-2 filed his affidavit in evidence. In his affidavit, OP-2 stated that he has been

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          running Govt. of NCT of Delhi approved nursing home in the nameof “Shri Shyam Nursing Home” at registered Address i.e. Pkt-6 House No. 212, Sector-22, Rohini and proved Registration Certificate of OP-2 bearing no. DHS/NH/1211 dated 15.10.2011 forthe period of 3 years and DGHS/NH/1211 dated 04.08.2016 valid for the period of 3 years i.e. up to 2019 and further stated that Smt. Anita Agarwal was admitted in the Nursing Home for her treatment during the period on 19.03.2016 and was discharged on 25.03.2016. This witness further stated that during her stay at the nursing home and thereafter none of the inspecting staff of OP-1 came for a visit or inspection.

9.       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 and there is nothing on record to disbelieve the case of the complainant. The documents and evidence of the parties shows that the wife of the complainant i.e. Smt. Anita Agarwal was hospitalized in Shri Shyam Nursing Home for the treatment of Acute Gastroenteries with Septicemia. This fact is not disputed by OP.The sole defence taken by OP-1 is controverted by the statement of OP-2. Moreover, if OP-2 is a 9 bedded hospital/nursing home and for that the complainant cannot be faulted. The other defence taken by OP-1 that no nursing staff nor any Doctor was found in the hospital is also controverted by the statement of OP-2 that no staff of OP-1

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          came for inspection. Thus, OP-1 ought not to have refused theclaim of the complainant. Thus, it appears that OP-1 has taken a false and bogus defence and in these circumstances, this forum is of opinion that OP-1 was not justifiedin denying the full claim ofthe complainant. Thus, OP-1 is held guilty of deficiency in service and unfair trade practice.

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

ii) To pay to the complainant an amount of Rs.15,000/- as compensation for harassment and mental agony

11. 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 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.

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12. 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 4^th day of November, 2019.

BARIQ AHMED                         USHA KHANNA                         M.K. GUPTA

   (MEMBER)                               (MEMBER)                         (PRESIDENT)

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