Delhi

West Delhi

CC/11/140

Mr. NareshKumar Jain - Complainant(s)

Versus

National Insurance Company - Opp.Party(s)

12 Sep 2017

ORDER

CONSUMER DISPUTES REDRESSAL FORUM (WEST)

                            GOVERNMENT OF NCT OF DELHI

  150-151 Community Centre, C-Block, JanakPuri, New Delhi – 110058

                                                                                     Date of institution:10.03.2011

Complaint Case. No.140/11                                           Date of order:12.09.2017

IN  MATTER OF

Mr. NareshKumar JainS/o Sh. R.K. Jain R/o  C-4C, 314JanakPuri, New  Delhi-110058.

Complainant

VERSUS

1.        National Insurance Company, Divisional Office-XIV, Plot No. 5, Second    and Third Floor, DPBlock, Local Shopping Centre, PitamPura, Delhi-110088

                                                                                                            Opposite party no.1

2.        Sh. HemrajJain  Hospital and Maternity Home, Nursing Home No. 1 , Block –C1JanakPuri, New Delhi-110058.

Opposite party no.2

ORDER

R.S. BAGRI,PRESIDENT

Shri Naresh Kumar Jain named above herein the complainant has filed the present complaint undersection 12 ofthe Consumer Protection Act  against  National  Insurance  Company and another  herein after referred  as the opposite parties for directions to the opposite party no. 1 to release mediclaim of the complainant  of Rs. 62,752/-with  interest  @ 18%  p.a. and pay Rs. 25,000/-  towards compensation on account of  mental and financial

 

suffering and Rs. 11,000/- as litigation expenses .

The brief relevant facts necessary for disposal of the present complaint as stated are that the complainant is holding a mediclaim policy no. 360700/48/09/8500005153 of the opposite party no. 1 for his entire family.  Smt. Sushila Jain wife of the complainant was hospitalized in the opposite party no. 2 from 11.10.2010 to 18.10.2010 for treatment of   2^nd degree uterovaginal prolapse. He spent Rs. 62,752/- on her treatment.  The complainant  submitted  claim  of Rs. 62,752/- with the opposite party no. 1.  But the opposite party no. 1 vide letter dated 03.02.2011 informed the complainant that his claim is declined on the ground that the company shall not be liable to make any  payment  under this policy  in respect of any claim if such claim be in any manner fraudulent or supported by any fraudulent means or  device whether  by the insured person or any other person acting on his behalf.Hence the present complaint for directions to the opposite party no. 1 to release mediclaim of the complainant  of Rs. 62,752/- with  interest  @ 18%  p.a. and pay Rs. 25,000/-  towards compensation on account of  mental and financial suffering and  Rs. 11,000/- as litigation expenses .

After notice the opposite party no. 1 appeared and filed replycontesting  the complaint raising preliminary objections that the complaint is   misconceived , not tenable and abuse of law.  The complainant has  concealedtrue and material facts.  The present case involves complicated questions of fact and law and can not be decided by this Forum in summary

proceedings. On merits the opposite party no. 1 admitted that the complainant is a mediclaim policy holder of the opposite party no.1.  The complainant submitted claim of Rs. 62,752/-.  The opposite party no. 1  appointed M/s Alankit Health Care TPA Ltd. investigator/surveyor.  Who submitted report that on investigation  nolab details found or no record found in the hospital and claim found fraudulent and  on the basis of  investigation report the claim is rejected under exclusion clause  5.6 of the medicalim insurance policy of the complainant.  All other allegations of the complainant are vehemently denied and once again prayed for dismissal of the complaint.

But despite service of notice none appeared for the opposite party no. 2 and the opposite party no. 2  was proceeded  against ex-parte vide order dated 19.03.2014.

The complainant  filed rejoinder to the reply  of the opposite party no. 1 controverting  stand  taken  by the opposite party no. 1  in reply reiterating his stand taken in the complaint .  When Sh. Naresh  Kumar Jain  complainant was asked  to lead evidence he tendered  in evidence his affidavit  narrating facts of the complaint.  Healso filedletter dated 03.10.2013 from the

opposite party no. 2 , case sheet  of Smt. Sushila  Jain  along with all medical  documents regarding  treatment of Smt. Sushila Jain and  documents of insurance policy.

When the opposite party no. 1 was asked to lead evidence they tendered in evidence affidavit of  Sh. Balwan Singh A.O. narrating facts of their reply.   The opposite party no. 1  also relied  upon Annexure R-1 letter dated 11.10.2010 , Annexure R-2 letter of repudiation dated 02.12.2010, Annexure R-3 letter dated 03.02.2011 of non settlement of mediclaim and  AnnexureR-4  terms and conditions of mediclaim  insurance policy. 

We have heard the complainant  in person  and learned counsel  for the opposite party no. 1and have gone through the record carefully and thoroughly .  It is admitted case of the parties  that the complainant submitted  mediclaim of Rs. 62,752/- with the opposite party no. 1.  The opposite party no. 1 appointed  M/s Alankit Health Care TPA Ltd.   surveyor /investigating agency  to investigate  claim of the complaint. They submitted reportAnnexure  R-2  stating that investigation has been carried out and no lab details  found or no record found in the hospital  and  claim found  fraudulent.

From perusal of affidavit of Complainant and  documents placed on record by the complainant it reveals thatSmt. Sushila Jain wife of the complainant was  diagnosed with second degree uterovaginal prolapse and

was  hospitalized in the  opposite  party no. 2  from 11.10.2010 to 18.10.2010 and surgery was conducted on 16.10.2016 in the opposite party no.2. The opposite party no.2  has given in writing  that Smt. Sushila  Jain remained  admitted in the opposite party no. 2 from 11.10.2016 to  18.10.2010 and was operated on 16.10.2010.  There is also receipt  of payment of Rs. 62,752/-  by the complainant to the opposite party no. 2.   The  complainant from his affidavit and documents isable to prove his versionthat his wife was hospitalized inthe opposite party no. 2 and he spent Rs. 62,752/- on   her treatment.   The report of M/s  Alankit Health Care TPA Ltd.  surveyor appointed by the opposite party no. 1 is not reliable and trust worthy as the surveyor report is not  supported by affidavit of the surveyor.  Therefore, the opposite party no. 1has  wrongly  rejected the claim of the complainant  under exclusion clause  5.6 of  Annexure R-4   terms and conditions of the mediclaim insurance policy. Hence the opposite party no.1 adopted unfair trade practice and is liable to  make payment  under the policy in respect of the claim filed by the complainant.

In view of the above discussion and observation   we direct the opposite party no. 1  to pay mediclaim of the complainant  of  Rs. 62,752/- alongwith interest @ 9% from filing of the complaint till actual realization and pay

 

 

Rs. 10,000/- as compensation for mental agony, pain, harassment and litigation expenses.

Order pronounced on : 12.09.2017

• Compliance of the order be made within 30 days after receipt of the order.
• Copy of order be sent to the concerned parties free of cost.
• Thereafter, file be consigned to record.

                  

(PUNEET LAMBA)                                                               ( R.S.  BAGRI )

                         MEMBER                                                                       PRESIDENT