DISTRICT CONSUMER DISPUTES REDRESSAL FORUM  (CENTRAL)

MAHARANA PARTAP BUS TERMINAL: 5^th  FLOOR.

KASHMERE GATE DELHI.

No. DF / Central/ 2015

Ashish Kumar Aggarwal

S/o Sh. Ram Narain Aggarwal

R/o E-106, FF, East Vinod Nagar, Delhi-110091                                                                             ..........Complainant

Versus

1.M/s New India Assurance Co. Ltd

902-903, Hemkunt House, 9^th Floor, RajendraPlace,

New Delhi-110008

2.Raksha TPA Pvt Ltd

C/o Escorts Corporate Centre,

15/5, Mathura Road,

Faridabad, Haryana 121003

3. Sukhda Hospital

Local Shopping Centre,

Near R- Block, Greater Kailash-I

New Delhi-110046

                                 ..........Respondent/OP

BEFORE

SH. RAKESH KAPOOR, PRESIDENT

SH. S. N. SHUKLA, MEMBER

ORDER

Per Sh. RakeshKapoor, President 

    The complainant had purchased a mediclaim policy from OP1 which was effected and was valid from 25.4.2011 to 24.4.2012 infact he had purchased the policy in the year 2007 and had been renewing the same year after year.  It is alleged by the complainant that he had suffered a dislocation  in shoulder and had to be operated upon on 8.7.2012 and was discharged on 9.7.2012.  He had incurred an expenditure of Rs. 16041/- and had lodged a claim with OP1.  The claim was not paid which lead to the filing of the present complaint.  The Ops 1 and 2 have contested the complaint and has filed a written statement. They have denied any deficiency in service and have claimed that the complaint is liable to be dismissed.

Para 6 of the preliminary objections of the written statement is relevant for the purposes of the disposal of the complaint and is reproduced as under:-

6. That the complainant has concealed the material facts from this Hon’ble Court, therefore, the complaint is liable to be dismissed. The true facts of the case are that a mediclaim policy bearing no. 31230034110100000462 valid from 25.7.2011 to 25.7.2012. On receiving the intimation on 14.7.2012 a claim form was received along with photocopy of policy. On receiving the same the company referred the matter to TPA who after scrutinizing the claim documents wrote a letter dated 28.7.2012 to the complainant for the following documents/ queries:-

(i) Treating Doctor certificate justifying indication for hospitalization in this case.

(ii) Copy of indoor case papers and vital charting.

(iii) Treating doctor certifciates regarding time of admission & time of discharge.

(iv) Copy of detailed operation notes.

(v) Treating doctors certificate mentioning type of anesthesia used in procedure.

But no reply for the same was received. Therefore, the TPA wrote reminder dated 13.8.2012 & 28.8.2012. But  no reply was received. Therefore, finally a letter dated 12.9.2012 was sent to explain the aforesaid queries and it was informed that in the absence of any proper reply the file will be closed. No reply was received even, thereafter, therefore, the file was closed as NO CLAIM. Therefore, the present claim is not maintainable and is liable to be dismissed with heavy costs. The present complaint is  therefore, misconceived and against the law and is, therefore, not maintainable and is liable to be dismissed.

    The Ops have contested the complaints on merits and have reiterated that the claim has been rightly denied to the complainant.

    We have heard arguments advanced at the bar and have perused the record.

    Courts on a number of occasions have impressed upon the officers of the insurance policies who deal with passage of claims to act in a manner which advances the purpose for which an insurance contract has been entered into. It has been impressed on them not to reject the claims on flimsy grounds. The present one is such a case where the claim has been rejected purely on whims and fancies. 

    OP2 M/s Raksha TPA Pvt Ltd is an agent of OP1 and was required to investigate the claim lodged by the complainant.  It was the duty of OP2 to have visited the hospital where the complainant was  ldoged and to gather evidence with regard to the claim.  Rather than doing the work assigned to it it has asked the complainant to supply it with certificates from the doctors with regard to the hospitalization etc. Had OP2cared to visit the hospital and obtain copies of the record , it would have been able to process the claim  rather than closing the claim as “No Claim”. OP1 was duty bound to get the case investigated in a law full manner. The way the claim has been denied to the complainant shows the reckless manner in which OP1 and OP2 are dealing with the matters.   We, therefore, hold OP1 and OP2 deficient in rendering services to the complainant. We directOP1 as under:-

1. Pay to the complainant a sum of Rs. 16,041/- along with interest @ 10% p.a. from the date of institution of this complaint i.e. 18.4.2013 till payment.
2. Pay to the complainant a sum of Rs. 15000/- as compensation for pain and agony suffered by the complainant.
3. Pay to the complainant a sum of Rs. 5000/-as cost of litigation.

     Copy of the order be made available to parties free of cost as per law.

    File be consigned to R/R.

   Announced in open sitting of the Forum on_____________

       ( S N SHUKLA )          ( RAKESH KAPOOR )

          MEMBER                 PRESIDENT