Haryana

Gurgaon

CC/146/2010

Vinod Alagh - Complainant(s)

Versus

New India Assurance Co. Ltd - Opp.Party(s)

20 May 2016

ORDER

                             DISTRICT   CONSUMER   DISPUTES   REDRESSAL FORUM,GURGAON-122001

                                                                               Consumer Complaint No: 146 of 2010                                                                                                                                                   Date of Institution: 25.02.2010                                                                                                                                                       Date of Decision: 20.05.2016

Vinod Alagh s/o late Sh. Jagan Nath Alagh, R/o H.No.347, Sector-14, Gurgaon.                                                                                                                                                                                                                     ……Complainant.

                                                Versus

The New India Assurance Co. Ltd

Main Office: Gulab Bhawan, 6, Bahadur Sahah Zafar Marg, New Delhi-110002 through its Chief Manager.

 

Branch Office: Gurudwara Road (opposite Kamla Nehru Park) Gurgaon through its Divisional Manager.

 

..Opposite parties

                                                                                               

Complaint under Sections 12 & 14 of Consumer Protection Act,1986                                                                  

 

BEFORE:     SHRI SUBHASH GOYAL, PRESIDENT

SMT JYOTI SIWACH, MEMBER

                   SH.SURENDER SINGH BALYAN, MEMBER.

 

Present:        Shri Amit Deshwal, Adv for the complainant.

                    Shri V.K.Bhardwaj, Adv for the OPs.

 

ORDER       SUBHASH GOYAL, PRESIDENT.

The case of the complainant, in brief, is that he was having a medi-claim insurance policy bearing No.323200/34/09/11/00001328 which was valid w.e.f. 02.08.2009 to 01.08.2010 which was renewed on the basis of previous insurance policy No.3232003407200000734. The complainant had been obtaining the medi claim insurance policy from the OP since 2002 and continued up to 01.08.2010. On 09.08.2009 the complainant was admitted to City Hospital, New Delhi where operation was conducted  and thus, he incurred a sum of Rs.1,24,241 vide Bill No.09-10/7517 dated 12.08.2009. The complainant lodged the claim with the OP but the OP has passed a part payment of Rs.58,606/- instead of valid claim of Rs.1,24,241.83. He also sent legal notice to the OP to release the full amount but of no use. Thus, the opposite parties are deficient in providing services to the complainant. The complainant prayed that the opposite parties be directed to reimburse the remaining claim amount of R.65,636/- with interest. He also sought compensation of Rs.50,000/- for harassment and mental agony.

2                 The complainant in support of his claim has filed his affidavit, copy of insurance policy Ann-A, final bill of City Hospital, New Delhi Ann B, details of payment Ann-C, copy of legal notice Ann-D, postal receipt Ann-E, Medi-claim Policy Ann-F.

3                 OP in its written reply has alleged that complainant has already been paid due amount to him i.e. Rs.58,606/-as per rates given in the policy and the amount was accepted by the complainant without any protest or objection. It was not open to him to hire the room or expert of the highest rent or fee. The insured was entitled to reimbursement of reasonable, customary and necessary expenses under the policy on the rates as mentioned in Para no.2 of mediclaim policy e.g. 1 % as room rent and so on so forth. Thus, there was no deficiency in service on the part of the opposite party.

4                 We have heard the learned counsel for the parties and have perused the record available on file.

5                 Therefore, from the facts and circumstances of the case, evidence on the file and the arguments advanced by the counsel for the parties it emerges that the complainant has filed the present complaint against the OPs alleging deficiency in service on their part on the ground that he was holding a medicalim policy since 2002 and during the subsistence of the insurance policy the complainant fell ill and was operated at City Hospital, New Delhi where a sum  of Rs.1,24,241.83 were incurred by him but the OP has made the payment of only Rs.58,606/- out of Rs.1,24,241.83 and thus, the opposite parties were deficient in providing services to the complainant.

6                 However, the contention of the OP is that due amount of Rs.58,606/- has already been paid to the complainant as per rates as prescribed in the policy and for the remaining claim he is not entitled as per the policy terms and conditions i.e. clause 2.3 and 2.4.

7                 Therefore, from the facts and circumstances of the case and evidence on file it emerges that the complainant was having a mediclaim policy and during the subsistence of the same he was admitted in City Hospital, Delhi where he incurred a sum of Rs.1,24,241.83. It is also admitted fact that a sum of Rs.58,606/- has been paid to the complainant. However, in view of clause 2.10 of the Mediclaim Policy it emerges that the complainant is having Hospitalization Benefit Policy (Zone II) and thus, the case of the complainant falls under clause 2.10(b), according to which the complainant was entitled to 100 % reimbursement of the sum insured. Therefore, OP cannot take the shelter of clause 2.3 and 2.4 of the policy which is not applicable to the facts and circumstances of the case and thus, the rejection of the claim of the complainant tantamounts to deficiency in service on the part of the opposite parties.

8                 Therefore, we direct the opposite parties to reimburse the balance amount of Rs.56,345/-(Rs.52801 + Rs.1182+ Rs.1772 + Rs.590 as shown in Annexure C)(though he is not entitled to Rs.8700/- as room rent) along with interest @ 9 % p.a. from the date of filing of the present complaint i.e. 25.02.2010 till realization. The complainant is also entitled to compensation for harassment and mental agony as well as litigation expenses to the tune of Rs.10,000/-. The OPs shall make the compliance of the order within 30 days from the date of receipt of the copy of this order. The parties be communicated of the order accordingly and the file be consigned to the records after due compliance.

Announced                                                   (Subhash Goyal)

20.05.2016                                                       President,

                                                                   District Consumer Disputes

                                                                   Redressal Forum, Gurgaon

 

(Jyoti Siwach)        (Surender Singh Balyan)

Member                 Member