Haryana

Ambala

CC/127/2013

PARAS GUPTA - Complainant(s)

Versus

NIC CO. - Opp.Party(s)

P.K. Bansal

13 Jun 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMBALA.

 

           Complaint Case No.      : 127 of 2013

Date of Institution         : 23.05.2013

            Date of Decision            : 13-06-2017

Paras Gupta son of Shri. Girish Gupta, resident of House No. 17-B, Raja Park, Ambala Cantt.                                                                            

……Complainant.

Versus

National Insurance Company Limited, 106, Railway Road, Ambala Canotnment, Ambala through its Divisional Manager.  

                                                                   ……Opposite Party.

Complaint Under Section 12 of the Consumer Protection Act.

 

BEFORE:   SH. D.N. ARORA, PRESIDENT.

                   SH. PUSHPENDER KUMAR, MEMBER.

                   MS. ANAMIKA GUPTA, MEMBER.

                  

Present:       Sh. P.K. Bansal, counsel for complainant.

                   Sh. S. Rashmi, counsel for OP.

ORDER.

                    In nutshell, brief facts of the complaint are that the complainant purchased a medical policy from the OP on the persistence of the representatives of opposite party; thereby the representatives of the OP assured that all the hospitalization benefit will be given to the policy holder. The complainant has also insured his wife Smt. Pushp Gupta and also his daughter Miss Saanvi (infant child) vide policy No. 420400/48/12/8500000216 valid with effect from 19-10-2012 to 18-10-2013. The complainant has paid an amount of Rs. 2,633/- to OP for the said policy for himself and for his entire family and OP disclosed the fact that the insured amount of Rs. 75,000/- for the complainant and Rs. 75,000/- for his wife and Rs. 50,000/- for his child will be given at once; if he is hospitalized during this insurance period. The complainant has submitted that he had some problem in his right ear, on which, he approached Dr. Raman Abrol, opp. Parade Ground, Chandigarh and on 18-10-2012, the doctors there examined the complainant’s ear carefully and then swelling started and the complainant took medicines to avoid further ailment but he did not recover and consequently he was advised for operation. As per advice of the doctor, the complainant got himself admitted in the hospital at Advanced ENT ENDOSCOPY Centre in Chandigarh and the said Dr. Raman Abrol admitted the complainant on 22-04-2013 and conducted operation of his right ear and he was discharged on 23-04-2013 and a sum of Rs. 30,000/- were charged by the hospital authorities for operation, admission and tests etc. vide receipt No. 20840 dated 23-04-2013. Thereafter, complainant lodged his medical claim with the OP vide file No. 20130422B009R3A040 and submitted all the relevant documents but the OP put him off on one pretext or the other. The complainant was asked to furnish infrastructure details of hospital i.e. No. Beds, which was not possible for the complainant. The complainant was not paid any amount despite many requests. Hence, the complainant,  has prayed  that the OP may kindly be directed to pay an amount of Rs. 75,000/- sum insured under the policy in question along with interest @ 18% p.a, Rs. 50,000/- on account of deficiency in service and unfair trade practice and Rs. 22,000/- as costs, to the complainant.   

2.                Upon notice, OP appeared through counsel and tendered reply raising preliminary objection qua maintainability of complaint, cause of action and concealment of true facts.  On merits, it has been submitted that the company shall not be liable to make any payment under this policy in respect of any expenses incurred in the Hospital which is not of less than 10 beds in the hospital and the complainant admitted in the hospital was having only six beds. Many letters were written to the complainant regarding details of the beds in hospital and registration of the hospital but the complainant never submitted any detail.  The claim of the complainant was duly repudiated by the company/opposite party by the conditions NO. 2.1 of the policy in which it is specifically mentioned that the company shall not be liable to make any payment under this policy, if the person will take the treatment from a hospital having less than 10 beds and this condition is incorporated in clause C-Town, and Ambala comes under clause C Town.  As such, the OP has prayed that the complaint is liable to be dismissed with costs.

3.                To prove his version, counsel for the complainant tendered affidavit as Annexure CX alongwith documents as Annexures C1 to C-15 and closed the evidence. On the other hand, counsel for OP tendered affidavit Annexure RX alongwith document as Annexure R-1 to R-9 and closed the evidence.

4.                We have heard learned counsel for the parties and gone through the case file very carefully.  It is admitted facts that the complainant got Hospitalization Benefit Policy for the period of with effect from 19.10.2012 to 18.10.2013 as the payment of premium Rs.2,633/- and the sum assured  amount of Rs. 75,000/- for the complainant,  Rs. 75,000/- for his wife and Rs. 50,000/- for his child as per annexure C14. It is also admitted the complainant, during the policy period got treatment from Dr. Raman Abrol, Advanced ENT ENDOSCOPY CENTRE, opp. Parade Ground, Chandigarh on as per annexure C1. As per document annexure C-4, the complainant has paid an amount of Rs. 30,000/- regarding the aforesaid treatment. The complainant had submitted his claim on account of medical expenses incurred by him and but the OP has wrongly repudiated his claim by the company/opposite party.

                   On the other hand counsel for the company/opposite party has argued that in view of the conditions No. 2.1 of the policy in which it is specifically mentioned that the company shall not be liable to make any payment under this policy, if any policy holder take the treatment from a hospital having less than 10 beds and this condition is incorporated in clause C-Town, and Ambala comes under clause C Town.

                   We have perused the document annexure R2, it is observed that the policy document is incomplete, therefore, we cannot presume that the policy document tendered by the opposite party is belonging to the case of the complainant. Further, the opposite party can produce the complete policy detail at any time during the pendency of the case but he did not produce the same, so, this Forum draws an adverse inference against the OP as they have withheld the best evidence which was in their possession.                          

5.                In view of the aforesaid discussion, we are of the considered view that the opposite party has wrongly withheld the genuine claim of the complainant, for which opposite party is liable to pay to the complainant.  Hence, it is unfair trade practice as well as deficiency in service on the part of the opposite party withholding the claim of the complainant, As such, he is liable to pay a sum of Rs. 30,000/- to the complainant alongwith interest and costs which is assessed to the tune of Rs. 3,000/-.   Hence, OP is directed to comply with the following directions within thirty days of the receipt of copy of the order:-

1. To pay a sum of Rs.30,000/- to the complainant alongwith interest @ 9% per annum from the date of filing the complaint till actual payment. If the opposite party failed to pay the above said amount within the stipulated period, then OP will be liable to pay further interest @ 12 % per annum on the awarded amount for the period of default. 
2. And to pay a sum of Rs. 3,000/- as costs on account of litigation.

          Copies of the order be sent to the parties concerned, as per rules.  File after due compliance be consigned to record room.

 

ANNOUNCED ON:      13.06.2017                                 Sd/-

                                                                                      (D.N. ARORA)

                    PRESIDENT      

         

                Sd/-

(PUSHPENDER KUMAR)

                                                                                MEMBER

 

                                                                                     Sd/-

   (ANAMIKA GUPTA)

                                                                               MEMBER