O R D E R
SUBHASH GUPTA, MEMBER
The complainant has filed the present complaint under section 12 of Consumer Protection Act, 1986 hereinafter to be referred as the ‘Act’ against the Opposite Parties, hereinafter to be called as OPs. The brief facts in the complaint are that the complainant and her husband Sh. Praveen Gulati obtained a mediclaim policy bearing 350304/81/13/8500000186 for a joint sum assured of Rs.5,00,000/- covering 4 family members i.e. complainant, her husband and two children effective from 16.4.2013 to 15.4.2014. This policy was further renewed bearing policy No.350304/48/14/8500000154 effective from 16.4.2014 to 15.4.2015. It has been further pleaded that during the existence of policy the complainant was admitted in the B.L.Kapur Super Specialty Hospital, Pusa Road, New Delhi on 9.9.2014, 19.9.2014, 26.9.2014 and 4.10.2014 for treatment of Autoimmune Hemolytic anemia(mixed type) and incurred a sum of Rs.3,56,240/- towards medical treatment. It has further pleaded that at the time of purchase of the policy the complainant was assured that the OP-2 will provide cashless facility during the illness of the policy holders. It has been pleaded that the OP-2 rejected the request of cashless facility vide letter dated 10.9.2014 and again on 7.10.2014. It has been further pleaded that the claim of the complainant has been rejected by the OPs on the grounds that the genetic disorder was not covered under the policy. It has been pleaded that the treating Doctor has given a certificate stating therein that the problem diagnosed is not a genetic disease and is not link to thalassemia traiat. On the basis of the pleadings the complainant is seeking reimbursement of Rs.3,56,240/- spent on the treatment along with interest @ 18%. The complainant is further seeking compensation of Rs.50,000/- towards mental, physical and financial harassment due to the acts of OPs. A sum of Rs.33,000/- has also been claimed as litigation cost by the complainant.
2. Notice of the complaint was issued to the OPs who have filed their written statement. Before we advert to the merits and demerits of the case it is important to note that during the course of the trial the OP brought and offered a cheque No.000554 dated 21.5.2015 for a sum of Rs.2,72,949/- drawn on Bank of Baroda, in favour of the complainant towards full and final settlement of the claim which was not acceptable to the complainant. The tendering of the cheque by the OPs tantamount to accepting the claim of the complainant. The OPs have not placed on record any calculation as to how the total claim of the claimant amounting to Rs.3,56,240/- was reduced to the extent of Rs.2,72,949/-. The act of the OPs in accepting the partial claim proves deficiency in service on the part of the OPs. Accordingly, the complainant is entitled to be awarded a sum of Rs.3,56,240/- along with interest @ 6% from the date of filing the complaint till its actual realization. The complainant is also awarded a sum of Rs.10,000/- towards compensation which will also include the cost of litigation.
Copy of this order be sent to the parties as per rules.
Announced this 11th day of May, 2016.
(K.S. MOHI) (SUBHASH GUPTA) (SHAHINA)
President Member Member
