O R D E R
K.S. MOHI, PRESIDENT
The complainant has filed the present complaint against the O.P u/sec. 12 of Consumer Protection Act, 1986. The facts as alleged in the complaint are that the complainant had taken a HAPPY FAMILY FLOATOR POLICY from the O.P.-4 for a sum of Rs.10,00,000/- on 30.12.2011. It is alleged that the aforesaid policy covered the risk of the entire family. It is alleged that the policy was extended from 16.12.2010 to 15.12.2013. It is alleged that during the period of insurance cover of policy the complainant’s mother was diagnosed for left side breast cancer. It is alleged that finally the mother of complainant was admitted at Madanta Hospital, Gurgaon on 25.4.2012 for surgery and discharged on 28.4.2012. It is further alleged that the complainant thereafter spent about Rs.2,99,870.94/- on her treatment. It is alleged that complainant after paying the said amount got herself discharged. It is alleged that in the month of July 2012, the OP-4 personally collected all the requisite document in original and later on he submitted the same at the office of OP-6 at Gurgaon Office on 13.8.2012. It is alleged that OPs rejected the genuine insurance claim of the complainant, the rejection letter sent by the OP’s Company, neither mentioned the cause of the rejection of the claim nor the same was signed by the Branch Manager. On these facts complainant prays that OPs be directed to pay the insurance claim of Rs.2.99,870.94/- alongwith interest and also to pay cost and compensation as claimed.
2. O.Ps appeared and filed their written statement. In its written statement O.P-1-4 has not disputed that complainant had taken policy referred above subject to the terms and conditions of the Insurance Policy. It is alleged that after the perusal of the claim of the complainant, it was clear that the liability of the OP Insurance Company could not have been ascertained and in such a situation, according to the terms and conditions of the insurance policy, the cashless facility could not be extended to the complainant. It is alleged that cashless rejection letter dated 25.4.12 clearly stated that “The hospital is requested to collect the expenses from the patient him/herself. However the patient may submit the hospitalization papers for reimbursement as per the policy terms and conditions”. It is alleged that the complainant never submitted the relevant documents which were necessary for process of the claim. It is alleged that the amount which is payable as per the report prepared by independent, IRDA approved third party administrator i.e. M/s E-Meditek, a cheque dt. 12.6.13, amounting to Rs.2,66,964/- has been prepared in favour of the complainant towards full and final settlement of the claim of the complainant. It is alleged that the complaint is to be dismissed on the ground that there is no deficiency of service on the part of OP Insurance Company. Dismissal of the complaint has been prayed for.
3. Complainant has filed her affidavit affirming the facts alleged in the complaint. On the other hand Shri S.S.Yadav, Dy. Manager has filed affidavit in evidence on behalf of O.P (OIC) testifying all the facts as stated in the written statement. Parties have also filed their respective written submissions.
4. We have carefully gone through the record of the case and have heard submissions of Ld. Counsels for the parties.
5. In the instant case the complainant has filed a claim for sum of Rs. Rs.2,99,870.94/-. During the course of proceedings, the Insurance Co. tendered a cheque dated 12.6.2013 of Rs.2,66,964/- which was received by the counsel of complainant on 30.8.2013 in the Forum. Counsel for complainant prayed that the case be preceded, however for grant of compensation for legal expenses and mental harassment. Counsel for complainant vehemently argued that though Insurance Co. accepted the claim of the complainant but he was compelled to file the present petition in the Forum which has caused inconvenience and mental harassment to the complainant for which he should be adequately compensated. Insurance Co. contended that the case of the complainant was processed promptly but there some delay was caused on their behalf to prepare the cheque. Some delayed occurred due to official functioning.
6. In view of the aforesaid discussion and circumstances of the case, we are of the considered view that the complainant has already received the cheque amounting to Rs.2,66,964/- the claim stands satisfied. However, the complainant needs to be compensated for unnecessary delay caused by the Insurance and also for mental agony. We are of the view that ends of justice will be met if the complainant is awarded a sum of Rs.5000/- as compensation towards mental agony and harassment and Rs.3,000/- towards litigation cost.
Copy of this order be sent to the parties as per rules.
Announced this 06th day of January, 2016.
(K.S. MOHI) (SUBHASH GUPTA) (SHAHINA)
President Member Member
