Per Hon’ble Shri. V. P. Utpat, President

 

This complaint is filed by consumer against the Insurance Company for deficiency in service u/s 12 of the Consumer Protection Act, 1986. Brief facts are as follows-

 

[1]                    Complainant is the resident of Guruwar Peth, Pune 411 042. He is senior citizen and has obtained mediclaim policy from the Opponent in the year 2006. The said policy was renewed from time to time. Lastly, the policy was renewed for the period of 13/3/2012 to 12/3/2013. Complainant had paid the premium regularly. On 2/5/2012 complainant was operated for his left eye and had spent Rs.32,000/- for hospitalization. This fact was intimated to the Opponent by the Complainant. Opponent called documents from the complainant. The said documents were submitted to the Opponent on 9/5/2012. Opponent has repudiated the claim by saying the said disease is excluded by the Exclusion Clause. The Opponent reopened the claim subsequently and sanctioned amount of Rs.9,000/-. As the Opponent has failed to reimburse the claim of Rs.32,000/- it has caused deficiency in service. Hence, complainant has filed present complaint against the Opponent.

 

[2]                    Opponent has engaged Advocate but failed to context the claim by filing written version. Hence, complaint is proceeded for hearing without written version.

 

[3]                    Complainant has filed his affidavit as well as all the documents which were submitted to the Opponent. It is the case of the complainant that the Opponent has issued cheque of Rs.9,000/-. Hence, he has restricted his claim to the tune of Rs.23,000/-on the ground of reimbursement, Rs.5,000/- for mental agony and costs of Rs.1,000/-. He has produced all the receipts, bill of hospitalization, discharge card, policy etc. It reveals from the bill that he had spent Rs.32,000/- for hospitalization charges. Opponent has failed to explain as to why claim of the complainant was restricted to the tune of Rs.9,000/-. Hence, I held that complainant has proved that the Opponent has caused deficiency in service and complainant is entitled for compensation and costs from the Opponent. I answer the points accordingly and pass the following order-

 

 

1.                  Complaint is partly allowed.

2.                  It is hereby declared that Opponent has caused deficiency in service.

3.                  Opponent is directed to pay Rs.23,000/- as reimbursement of medical bill, Rs.5,000/- towards compensation for mental and physical torture and Rs.1,000/- by way of costs of proceeding to the complainant, within six weeks from the date of receipt of copy of order.

4.                   If the amount is not paid or deposited within the stipulated period, it shall carry interest @ 9% p.a. from the date of filing till its realization.

5.                  Both parties are directed to collect the sets which are provided for the Members within one month from the date of order. Else those will be destroyed.

 

Copy of order be supplied to both the parties free of cost.

 

Place – Pune

Date – 05/12/2013