DISTRICT   CONSUMER   DISPUTES   REDRESSAL FORUM GURGAON-122001.

                                                                                                              Consumer Complaint No. 206 of 2010                                                                                                                                                   Date of Institution: 12.03.2010.                                                                                                                                                                            Date of Decision: 08.10.2015

Manoj Kumar S/o Sh. Ami Lal, R/o VPO Bachhod, Tehsil Narnaul, District Mohindergarh, at present residing at Wazirabad, Gurgaon.

                                                                                        ……Complainant.

                                                Versus

National Insurance Co. Ltd, Padam Singh Road, Karol Bagh, New Delhi through its Branch Office at Gurgaon.                    

                                                                                      …..Opposite parties.

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

BEFORE:     SH.SUBHASH GOYAL, PRESIDENT.

                    SMT JYOTI SIWACH, MEMBER.

                    SHRI SURENDER SINGH BALYAN, MEMBER

Present:        Sh.C.K.Sharma, Adv for the complainant.

                    Sh. Deepak Gupta, Adv for the OP.

ORDER        SUBHASH GOYAL, PRESIDENT.       

The case of the complainant in brief is that he had taken a Mediclaim Family Policy bearing No.360900/48/08/8500000202 for the period from 02.05.2008 to 01.05.2009 for himself. The complainant fell ill on account of acute  ocaculous chaleaystitie in the first week of Feb, 2009 for which the complainant had to be got admitted in East West Hospital, Sector-14, Gurgaon  which is an approved hospital of the Alankrit Health Care Ltd which is the TPA of the opposite party. The complainant has incurred a sum of Rs.32,576/-on his treatment. He submitted the claim with the opposite party but the claim of the complainant was repudiated vide letter dated 06.07.2009  on the ground that the hospital from which the complainant took treatment was outside the list of the NCR hospital and thus, on this false his claim was repudiated though the opposite party was liable to pay the claim under the Mediclaim policy. Thus, the opposite party is deficient in providing services to the complainant. He prayed that the opposite party be directed to reimburse the amount of Rs.32,576/- with interest @ 18 % p.a. He also sought compensation of Rs.30,000/- on account of transportation, harassment and mental agony suffered by the complainant. The complaint is supported with an affidavit and the documents placed on file.

2                 The OP in its written reply has alleged that list of hospitals at the time of issuance of the policy was attached with the policy and name of East West Medical Centre has not been mentioned in the list. Thus, the complainant has violated the terms and conditions of the insurance policy by not supplying the required papers and documents.. The claim of the complainant was rightly repudiated. Thus, the complaint is liable to be dismissed.

3                 We have heard the learned counsel for the parties and have gone through the case file very carefully.

4                 Therefore, from the facts and circumstances of the case, evidence on the file and the arguments advanced by the learned counsel for the parties, it emerges that he had taken a Mediclaim Family Policy bearing No.360900/48/08/8500000202 for the period from 02.05.2008 to 01.05.2009 for himself  and during the subsistence of the said policy complainant fell ill on account of acute ocalculous chaleaystitie  and remained admitted in East West Hospital, Sector 14, Gurgaon  for the period from 06.02.2009 to 13.02.2009 and incurred expenses of Rs.32,576/- in the said hospital. The complainant lodged the claim with the OP but the same was repudiated by the OP on 06.07.2009 on the ground that the said hospital was outside the list of NCR hospitals. However, absolutely there is no evidence on file in order to show that East West Hospital, Gurgaon from which the complainant took treatment was not included in the approved list of the hospitals. No policy has been placed on file in order to exclude the said hospital from the list of the approval hospitals for grant of reimbursement.

5                 It has come in evidence that the complainant has incurred expenses of Rs.32,576/- as shown Cash Memo No.A-5506 dated 06.02.2009. There is nothing on the file that the said bill was not genuine. Therefore, we hold that non reimbursement of the said bill tantamounts to deficiency of service on the part of the opposite party.

6                 Therefore, in view of above discussion, we accept the present complaint and direct the opposite party to reimbursement the amount of Rs.32,576/- to the complainant along with interest @ 9 % p.a. from the date of filing of the complaint i.e. 12.03.2010 till realization. The complainant shall also be entitled for a sum of Rs.5000/- for harassment caused to him and a sum of Rs.3100/- towards legal fee and litigation expenses. The OP shall make the compliance of this order within a period of 30 days from the date of receipt of the copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the records after due compliance.

Announced                                                   (Subhash Goyal)

08.10.2015                                                       President,

                                                                   District Consumer Disputes

                                                                   Redressal Forum, Gurgaon

(Jyoti Siwach)        (Surender Singh Balyan)

Member                 Member