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 mediclaim policy (Happy Family Floater Policy) bearing No.271500/48/2013/1289 valid for the period from 27.06.2012 to 26.06.2013 from the O.P. It is alleged that complainant’s daughter namely Kirti Gupta met with an accident at her home as she slipped and got her foot badly hurt and was admitted in Ganesh Ortho Trauma & Medical Centre, Delhi on 28.06.2012 for treatment. It is alleged that complainant intimated O.P about the said accident immediately through an email dated 28.06.2012 as complainant’s daughter was covered under the insurance policy and complainant needed money for getting his daughter treated. It is further alleged that the confirmation of email of intimation was also sent by O.P to complainant. It is alleged that daughter of the complainant was treated in the hospital for 5 days i.e. from 28.06.2012 to 02.07.2012 and thereafter was discharged as her treatment was complete. It is further alleged that as per the prescribed format of O.P company to file insurance claims the complainant filed his claim amounting to Rs.66,130/- along with all the bills and required relevant documents to O.P within seven days from date of discharge of his daughter from hospital for reimbursement of the hospital bills. It is alleged that the complainant has been repeatedly reminding and requesting the O.P to reimburse the amount paid by him but of no avail. It is further alleged that complainant was shocked to find that his claim was repudiated on 11.12.2013 on wrong and frivolous grounds and he has not been intimated about the same. Complainant has also sent a legal notice dated 02.01.2013 but to no avail. On these facts complainant prays that O.Ps be directed to pay the mediclaim amount of Rs.66,130/- with interest @ 24% p.a. and also to pay cost and compensation as claimed.
2. O.P appeared and filed written statement. In his written statement O.P has not disputed that complainant had taken policy refer to above. It has also not been disputed that complainant was admitted in Hospital for treatment of fracture for the period from 28.06.2012 to 02.07.2012. It has also not been disputed that the complainants have filed a claim in respect of the said treatment. It is alleged that the O.P company had asked the TPA to investigate the claim. The TPA of the O.P company after visiting the insured and obtaining various documents submitted the report concluding therein that the claim of the complainant was doubtful. The policy had been obtained after the accident accordingly the O.P company repudiated the claim. Dismissal of the complaint has been prayed for.
3. Complainant has filed his affidavit affirming the facts alleged in the complaint. He has also proved documents exhibited as Ex. CW-1/A to CW-1/I.
4. We have considered the submissions raised by counsels for the parties and have also perused the record.
5. In the instant case the O.P repudiated the claim on the ground that it appear to the O.P that claim of the complainant was doubtful because the accident in question took place just on the next day of taking of the policy. The O.P has not placed on record any documentary evidence as to how it came to the conclusion that claim was doubtful. During the proceedings the O.P released a sum of Rs.57,148/- as full and final settlement of the claim and the remaining amount was not paid by O.P being in admissible as per terms of the policy. It would be seen that initially the O.P rejected the claim in toto on flimsy grounds and thereafter of their own released the aforesaid amount. The O.P has also not placed on record any terms and conditions or any other justification for deduction of the amount. Therefore, the forum is of the opinion that let the total claim or Rs.66,130/- claimed by complainant be given to the complainant. Therefore, the O.P is directed to pay the balance amount to complainant within 30 days of receipt this order. The O.P shall also pay Rs.2,000/-towards harassment mental agony loss of time and Rs.1,000/- towards litigation cost.
Copy of this order be sent to the parties as per rules.
Announced this 16th day of December, 2015.
(K.S. MOHI) (SUBHASH GUPTA) (SHAHINA)
President Member Member
