BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.            

                                                          Consumer Complaint no. 24 of 2012                                                                          

                                                         Date of Institution         :    2.2.2012

                                                          Date of Decision   :   1.6.2016 

Dr.Amit Tayal, Dayal Nursing Home, Dabwali Road, Sirsa district Sirsa.

            ….Complainant.         

                                      Versus.

The New India Assurance Company Ltd., Sirsa through its Divisional Manager.

                                                                               ...…Opposite party.

         Complaint under Section 12 of the Consumer Protection Act,1986.

Before:        SHRI S.B.LOHIA…………………PRESIDENT

                  SH.RAJIV MEHTA………… ……MEMBER.  

Present:       Sh.A.K.Gupta,  Advocate for the complainant.

      Sh.Rakesh Bajaj, Advocate for opposite party.

ORDER

                   In brief, the case of the complainant is that he purchased one Health insurance policy no.363700/34/10/11/00000046 from the opposite party to the extent of Rs.3 lac which included a cumulative bonus to the extent of 50%. During the period of policy, the complainant met with accident and suffered a Duket Handle Tear Medial Miniscus+ACL Tear left knee while playing badminton in November, 2010. The complainant was underwent arthroscopy operation and remained in the hospital from 30.3.2011 to 2.4.2011 and after that remained under treatment with Dr.Pankaj Grover, MRW, Pankaj Physiotherapy and Rehabilitation Centre, Hisar road, Sirsa from 4.4.2011 to 20.5.2011. Thereafter, he submitted the medical bills amounting to Rs.114088, but Rs.44936/- were sanctioned. He immediately lodged a protest and after several requests, the revised claim was settled at Rs.60834/- instead of Rs.44936/- considering the claim for Rs.2 lacs, which is against law and against the insurance norms. Hence, the present complaint for payment of Rs.1,14088/- after deducting the amount already paid alongwith interest and also for compensation. 

2.                Opposite parties in their reply have admitted the purchase of the Health insurance policy by the complainant worth  Rs.1,00,000/- with cumulative bonus upto 50% on the sum insured from 2009 to 2010. In the next renewal, the complainant enhanced the sum insured by Rs.1,00,000/- and thus, the sum insured was Rs.2,50,000/- in the year 2010-11. It is admitted that sum of Rs.44936/-  was settled and, thereafter a short payment of Rs.15898/- was reimbursed to the complainant. The claim of the complainant was processed in accordance to clause 2.1 and 2.3 of the policy on the sum insured Rs.2,00,000/- excluding cumulative bonus. It is further pleaded that if the sum insured is either for Rs.2,00,000/- or for Rs.3,00,000/- it does not mean that the claim has to be settled for the whole amount.

3.                Both the parties have led their evidence in the form of affidavits and documents. The complainant has tendered in evidence Ex.C1 to Ex.C20; whereas the opposite party has tendered Ex.R1-affidavit of Sh.R.K.Indora, Divisional Manager.

4.                 We have heard learned counsel for the parties and gone through the record of the case and written arguments placed on record by both the parties.

5.                It is admitted fact that complainant was insured with Op for Rs.1,00,000/- plus 50% bonus and, thereafter renewed its policy for Rs.1 lac. It is not disputed that he had incurred Rs.1,14,088/- on his treatment. But, the Ops passed out only Rs.44936/- and further revised his claim for Rs.60834/- after deducting the said amount. Now, as per the case of the complainant, he was entitled for his health claim on the insured sum of Rs.300,000/-, whereas the opposite party has settled his claim on sum insured Rs.2 lac.  This fact is clear from the document Ex.C4 that the opposite party has settled the claim of the complainant to the extent of Rs.60834/- on sum insured rupees 2 lacs. It is also admitted by the opposite party in their reply that the claim of the complainant was processed in accordance to clause 2.1 and 2.3 of the policy on the sum insured Rs.2,00,000/- excluding cumulative bonus. The opposite party has failed to show any terms and conditions of the policy. Hence, in our view, when the insurance policy of the complainant was  for the sum insured Rs.2,00,000/- with 50% bonus then the complainant is entitled to recover his claim on the whole insured sum of Rs.300,000/-.

6.                As discussed above, the present complaint is hereby allowed. The opposite party is hereby directed to calculate the  claim of the complainant on total insured sum of Rs.3,00,000/- and thereafter, the calculated amount be given to the complainant after deducting the already paid claim amount. No order as to costs.  Compliance of this order be made within a period of 30 days from the date of receipt of copy of this order.  A copy of this order be supplied to the parties free of cost.  File be consigned to record room after due compliance.

Announced in open Forum.                                 President,

Dated:1.6.2016                       Member.              District Consumer Disputes

                                                                             Redressal Forum, Sirsa.