Delhi

North

CC/200/2017

LOVELY SINGH - Complainant(s)

Versus

THE ORIENTAL INSUARNCE CO. LTD. - Opp.Party(s)

KUNAL KUMAR SINGH

11 Oct 2021

ORDER

ORDER

PoonamMalhotra, Member:

 

1.         The brief facts of the present complaint are that the complainant is having a Happy Family Floater Policy with distinctive No.271601/48/2015/4873 whereunder she alongwith three other persons namely, Kunal Kumar Singh, Tushar Subrat & Punn Pragy, were insured under the said policy.  It is alleged that Tushar Subrat suffered from dengue fever and was admitted to Hans Charitable Hospital, Kingsway Camp, Delhi on 15/09/2015.  He was discharged from the hospital on 17/09/2015.  It is, further, alleged by the complainant that though intimation about the admission of Tushar Subrat into the hospital was given to the OP vide Reference No.1115387 but she was denied cashless benefit and the complainant was compelled to pay all the medical expenses out of her pocket.   Immediately after the discharge of Tushar Subrat from the hospital, claim with regard to the reimbursement of the expenses incurred by her was lodged with the OP alongwith all the relevant original documents through the agent namely, Sh. Shesh Nath Prasad.  Reminder letter dated 14/07/2016, Legal Notice dated 25/08/2017 duly served upon the OP and several requests to it for the redressal of her grievance were of no consequence. In view of the said facts, the complainant has prayed for directions to the OP to reimburse Rs.7,930/- to her towards the treatment of her son, Tushar Subrat, being insured under the said policy alongwith interest @18%p.a.from the date of payment of bill till its realization, Rs.60,000/- as compensation for the physical & mental agony and litigation cost.

 

2.         In response to the notice issued to the OP, none put up appearance and case proceeded exparte against it vide Order dated 23/03/2018.

 

3.         Evidence by way of Affidavit filed by the complainant in support of the averments raised by her in her complaint has not been controverted by the OP.  

Written Arguments filed by the complainant.

 

4.         Heard Arguments and perused the record.

 

5.         On perusal of the record, the facts with regard to the insurance, treatment and hospitalization of Tushar Subrat, denial of request for cashless hospitalization and consequent lodging of claim to the insurance company for the reimbursement of the expenses incurred on the treatment and hospitalization of her son Tushar Subrat are not in dispute.  On reading through the affidavit filed in evidence by the complainant it is observed that in Para19 of the said affidavit, the complainant has affirmed on oath that after the filing of the present complaint, out of her total claim of Rs.7,930/- the OP has transferred on 03/10/2017 an amount of Rs.6,719/- into her bank account.  So, the dispute that remains to be decided is only with regard to the balance Rs.1,211/- (i.e.,Rs.7,930/- minus Rs.6,719/-).  The fact that no Discharge Voucher was signed by the Complainant was recorded in the proceedings dated 25.04.2019.  In Para 2 of the Affidavit filed in evidence by the Complainant it is stated on oath by her that she has not entered into any agreement of settlement with the OP either before or after the filing of this complaint nor she had given any directions for the transfer of amount into her bank account.  Since the affidavit filed in evidence by the complainant has not been controverted by the OP, there is no reason for us to disbelieve the statements made on oath in the affidavit by her filed in evidence.  

 

 

6.         Taking the above facts and circumstances into consideration we hold the OP deficient in providing services to the complainant & direct it to reimburse the balance amount of Rs.1,211/- to the complainant.  We, further, direct the OP to pay Rs.500/- towards compensation for agony meted out by her and this amount shall include the cost of the present litigation.  Let the entire amount of Rs.1,711/-be paid to the complainant within 45 days from the date of this order.  If the OP fails to pay the amount so awarded to the complainant within the stipulated period of 45 days, the complainant shall also be entitled to get interest on the awarded amount @ 6% p.a. from the date of institution of the present complaint till the date of its actual payment to the complainant. 

 

Copy of this order be sent to the Parties as per rules and be uploaded on the website www.confonet.nic.in.  File be consigned to the Record Room.

 

 

Announced this of 11^th Day of October, 2021.    

 

 

 

 

 

   (ASHWANI KUMAR MEHTA)                                      (POONAM MALHOTRA)

                        Member                                                                          Member   

 

 

 

 

(DIVYA JYOTI JAIPURIAR)

President