Haryana

Sonipat

CC/118/2016

Sushil Chand Jain Advocate - Complainant(s)

Versus

The Oriental Insurance Co. Ltd. - Opp.Party(s)

Sandeep Goyal

16 Mar 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

SONEPAT.

               

 

                                Complaint No.118 of 2016                                              Instituted on:25.04.2016

                                Date of order:16.03.2017

 

Sushil Chand Jain Advoate, 150, Sector 1 Sonepat.

…Complainant.         

Versus

 

1.Oriental Insurance Co. Ltd. Atlas road, Sonepat through its Divisional Manager.

2.M/s Vipus Medical Corp. Pvt. Ltd. 515, Udyog Vihar, Phase V, Gurgaon.

 

                                                     …Respondents.

 

 

COMPLAINT UNDER SECTION 12 OF

THE CONSUMER PROTECTION ACT,1986

 

Argued by: Sh. Sandeep Goyal  Advocate for complainant.

           Sh. Surender Malik, Adv. for respondent no.1.

           Respondent no.2 ex-parte on 18.01.2017.

 

 

Before-    Nagender Singh-President.

Prabha Wati-Member.

J.L. Gupta-Member.

 

O R D E R

 

          Complainant has filed the present complaint against the respondents alleging therein that he is having family medi claim policy from the respondent no.1 since last 15 years and policy no.261600/48/2015/139 was issued on 18.4.2014.  During the above said policy w.e.f. 22.4.2014 to 21.4.2015 the complainant felt some problem in his right eyes and required cataract surgery as per opinion of Dr OD Sharma Eyes Specialist.  The complainant has decided to get the cataract surgery of right eyes from Medanta Hospital at Gurgaon.  His right eyes were operated on 31.10.2014. Out of surgery charges of Rs.85000/-, an amount of Rs.68000/- was paid by Focus Health Care Ltd. being the insurance company of complinant’s son.   The complainant after recovery lodged a claim of Rs.19000/- on 9.12.2014 as Rs.17000/- was paid in cash for the surgery, Rs.1000/- as registration charges and Rs.1000/- for medicine charges.  The complainant has requested the respondents several times to make the payment of Rs.19000/-, but of no use and that amounts to a grave deficiency in service on the part of the respondents. So, he has come to this Forum and has filed the present complaint.

2.        The respondent no.1 has appeared and filed the written statement, whereas respondent no.2 was proceeded against ex-parte vide order dated 18.01.2017.

          The respondent no.1 in its written statement has submitted that the complainant has not provided/submitted any medical record i.e. original papers & medical bills to the respondent no.1 and in the absence of the same, the claim cannot be considered. The complainant has not suffered any mental agony or harassment at the hands of the respondent no.1 and thus, he is not entitled for any relief and compensation and prayed for the dismissal of the present complaint.

3.        We have heard the arguments advanced by the learned counsel for the complainant and respondent no.2 at length.  All the documents have been perused very carefully and minutely.

          Ld. counsel for the complainant has submitted that the complainant is having family medi claim policy from the respondent no.1 since last 15 years and policy no.261600/48/2015/139 was issued on 18.4.2014.  During the above said policy w.e.f. 22.4.2014 to 21.4.2015 the complainant felt some problem in his right eyes and required cataract surgery as per opinion of Dr OD Sharma Eyes Specialist.  The complainant has decided to get the cataract surgery of right eyes from Medanta Hospital at Gurgaon.  His right eyes were operated on 31.10.2014. Out of surgery charges of Rs.85000/-, an amount of Rs.68000/- was paid by Focus Health Care Ltd. being the insurance company of complinant’s son.   The complainant after recovery lodged a claim of Rs.19000/- on 9.12.2014 as Rs.17000/- was paid in cash for the surgery, Rs.1000/- as registration charges and Rs.1000/- for medicine charges.  The complainant has requested the respondents several times to make the payment of Rs.19000/-, but of no use and that amounts to a grave deficiency in service on the part of the respondents.

          Ld. Counsel for the respondent no.1 has submitted that the complainant has not provided/submitted any medical record i.e. original papers & medical bills to the respondent no.1 and in the absence of the same, the claim cannot be considered. The complainant has not suffered any mental agony or harassment at the hands of the respondent no.1 and thus, he is not entitled for any relief and compensation and prayed for the dismissal of the present complaint.

          In the present case, the main plea of the respondent no.1 is that the claim of the complainant was not considered as the complainant has not provided/submitted any medical record i.e. original papers of treatment and medical bills to the insurance company.

          We have perused the insurance policy Ex.R1 which is valid and effective for the period 22.4.2014 to 21.4.2015 and during the validity of the insurance policy, the complainant has got treatment regarding his eyes.  Out of surgery charges of Rs.85000/-, an amount of Rs.68000/- was paid by Focus Health Care being the insurance company of complainant’s son as the parents were covered upto 80% of the surgery charges.  But when the complainant requested the respondent to make the payment of balance amount of Rs.17000/-, the same were not paid by the respondent company.  In our view, the respondent has wrongly & illegally not made the payment of Rs.17000/- to the complainant.  Accordingly, we hereby direct the respondent no.1 to make the payment of Rs.17000/- to the complainant and further to compensate the complainant to the tune of Rs.2000/- for rendering deficient services, harassment and under the head of litigation expenses.    

           With these observations, findings and directions, the present complaint stands allowed.

          Certified copy of this order be provided to both the parties free of cost.

File be consigned to the record-room.

 

 

(Prabha Wati)(J.L.Gupta)                   (Nagender Singh-President)

Member DCDRF  Member DCDRF                   DCDRF, Sonepat.

 

Announced: 16.03.2017