BEFORE THE SOUTH MUMBAI  DISTRICT  CONSUMER DISPUTES REDRESSAL FORUM,

                                                                    O.No.

Complaint No.SMF/MUM/CC/2016/6

   Date of filing :  05/012016                                                                                                     

                                                                           Date of Order:  09/11/2017

Shri. Mahendra C. Dasadia,

Address at – Flat No. 302,  Maygair Kumkum,

Plot No. 11, S.V. Road, Andheri (West),

Mumbai – 400 0 58.                                            ….. Complainant.    

  V/s.

1. The New India Assurance Company Limited,

          Divisional Office at – Divisional Office No. 114000,

          Mittal Chambers, 2^nd Floor, Nariman Point,

         Mumbai – 400 021,

2. Raksha TPA Private Limited,

     Registered Office at – Unit No.2,

     A-Wing, Time Square, Third Floor,

     Marol, Andheri-Kurla Road,

    Mumbai  - 400 059.             ….. Opposite Parties

                    Coram:

Shri. G.K. Rathod                 :   Hon’ble President

Shri. S.R. Sanap               :   Hon’ble Member

Appearance:  For Complainant       –        In person

                       For Opponent  No. 1          -        Adv. Smt. Sapna Bhuptany

                       Opponent No. 2         -        Ex-parte              

// JUDGMENT //

PER SHRI. G.K. RATHOD – HON’BLE  PRESIDENT

                   The contents of the complaint summarized as under :

                   The Complainant has obtained Mediclaim policy in the year 2012  from the Opponent No. 1.  The agreement was executed between the Complainant and the Opponent to that effect from time to time.  Both the parties  accepted the terms and conditions of the agreement, accordingly, the Complainant has paid the regular premiums. The Complainant has submitted his claim as he has operated for cataract in his eyes on  25/02/2015 and 18/03/2015.   As claim has repudiated by the Opponent No. 1, hence this case is filed. 

(2)              The Opponent No. 1 appeared and filed its written statement and denied all the contents of the complaint in toto.  It is submitted that this complaint is not maintainable, it is misconceived vexatious and without merit.  It is further submitted that the caption 5 condition and in specific clause 5-15  he has not complied and therefore, his claim is repudiated. 

(3)              The Opponent No. 2 remained absent and therefore, the complaint is proceeded ex-parte against the Opponent No. 2.

(4)              After perusal of the contents in the complaint, affidavit evidence  produced by the Complainant and the written statement, affidavit evidence produced  by the Opponent No. 1, as also, written arguments and documents filed by the Complainant and the Opponent No.1 , the  following points arouse for my consideration.

REASONING:
(5)               From the contents of the complaint, affidavit evidence, written arguments and oral arguments submitted by the Complainant it appears that the Complainant is a senior citizen aged about 83 years practicing advocate and he was having Mediclaim Policy from the Opponent No. 1 for the last more than 10 years and the same was renewed from time to time.  The last Mediclaim Policy bearing No. 11140034142500004777 renewed for the period 9/8/2014 to 8/8/2015, which is at Exh. 1.  The Complainant had cataract in his both eyes and the Complainant was to be operated and he was admitted in the hospital and operation was carried out on 25/2/2015.  By the letter dtd. 22/2/2015, the Complainant informed to the Opponent No. 1  through its authorized officer and the Opponent No. 2 about the cataract surgery and also requested to inform about the medical expenses claimed from the Opponent No. 1. The Complainant had paid Rs. 41,236/- towards the cataract operation and medical expenses for his left eye.  He has also operated for his right eye cataract and produced all the documents and for that he has incurred expenses amounting to Rs. 38,307/-.  The Complainant also informed by sending letter dtd. 26/03/2015 filed at Exh.D.  He has also submitted all the original bills to the Opponent No. 2.  The Opponent Nos. 1 and 2 referred to their letter dtd. 14/03/2015 requesting to submit more documents by sending letter dtd. 30/3/2015, filed at Exh. E and also another letter dtd. 6/4/2015 filed on record at Exh. F.  The Opponent No. 2 send a letter to the Complainant dtd. 13/4/2015, 7/5/2015 called upon the Complainant to submit the Original Pre-numbered, Preprinted duly signed and stamped final bill of the Hospital.  All the bills and originals as per requirement he has submitted.   The Complainant was having a Bank Account No. SB-26 in Indian Overseas Bank, Khar Branch. On 30/6/2015, he went to his Banker to update his Pass-Book of his said Account, the Complainant found that there were two entries of Rs. 24,000/- each  credited to the Account of the Complainant   on 12/6/2015 and 15/6/2015, the said entries were for the amount transferred by the Opponent No. 1 as against the claim of the Complainant under the said Mediclaim Policy.  The Complainant has made a total claim of Rs. 79,543/- for cost and charges of his both eyes cataract surgery.  However, the Opponent transferred only sum of Rs. 48,000/- to the Complainant.  It is further contended that the said Mediclaim policy of the Complainant is Rs. 2,50,000/-  and the Complainant has made a complaint to the Opponent is well within the limit of value about the said Mediclaim Policy, and therefore, the Complainant has issued a notice to the Opponent to pay the balance amount of Rs. 17,236/- and Rs. 14,307/- aggregating Rs. 31,543/-.  We heard the arguments of the Opponent and Complainant and we found that the Complainant is entitled for remaining balance of Rs. 31,543/-  and therefore, we found that there is a deficiency in service on the part of the Opponent No. 1.  Hence we answered the point Nos. 1 and 2 accordingly.  We found substance in the submission of the claim of Rs. 31,543/- of the Complainant  alongwith interest  @ 9% p.a. from the date  12/06/2015, on which date the Opponent No. 1 has partly paid his claim till realization of the amount.  Being a senior citizen the Complainant is entitled for Rs. 5,000/- towards compensation and Rs. 2,000/- for cost.

(6)              Accordingly, we proceed to pass the following order :    

//O R D E R//

1. The complaint is partly allowed.

2. The Opponent No. 1 shall pay Rs. 31,543/-  alongwith interest @9% p.a. from 12/06/2015 till its realization to the Complainant.  
3. The Opponent No.1 also shall pay Rs. 5,000/- towards compensation and Rs. 2,000/- towards cost to  the Complainant.    
4.  The Opponent No. 1 to comply the aforesaid order within a  period of (30) days from the date of receipt of this order.
5. No order as against the Opponent No.2.
6. Certified copy of this order be supplied to both the parties free of costs.       

       sd/-xxx                                                                 sd/-xxx

                   (Shri. S.R. Sanap)                                       (Shri.G.K. Rathod)

  Hon’ble  Member                                       Hon’ble President

Note:-  As the pleadings, affidavit, documents of the parties are in English, the order in the proceeding is passed for the better knowledge of the parties in English.

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