Delhi

New Delhi

CC/495/2016

Pooram Chand Aggarwal - Complainant(s)

Versus

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

02 Jun 2017

ORDER

CONSUMER DISPUTES REDRESSAL FORUM-VI

(DISTT. NEW DELHI),

 ‘M’ BLOCK, 1^STFLOOR, VIKAS BHAWAN, I.P.ESTATE,

 NEW DELHI-110001

Case No.C.C./495/2016                                 Dated:

In the matter of:

SH. Pooran Chand Agarwal,

A-3/98, Janak Puri,

New Delhi-110058

        ……..COMPLAINANT

VERSUS

1.     THE ORIENTAL INSURANCE COMPANY LTD.

        88 Janpath,

        New Delhi-110001

 

2.     Medi-Assist India TPA Pvt. Ltd.

        B-20, Sector-2, Noida-201301

 

       .... OPPOSITE PARTIES

 

MEMBER : NIPUR CHANDNA

ORDER

Complainant is a Senior Citizen and the Mediclaim policy holder of OP Co. vide its policy bearing no. 272900/48/2016/ 6511 w.e.f from 14.11.2015 to 13.11.2016.  It is alleged by the complainant that on 09.02.2016  due to vomiting and unconsciousness he was admitted to Sir Ganga Ram Hospital in Emergency vide admission casualty card no. 0482285 at 10.30 p.m. and was discharged on 13.02.2016.

It is alleged by the complainant that although it is mentioned in the Policy Documents that Op shall pay for Hospitalization expenses for medical / surgical treatment at any Nursing Home / Hospital in India as an in-patient defined in the policy, the TPA Medi. Asst. of OP Insurance Co. denied the cashless facility to him stating that “ The patient may obtain the treatment as per his treating Doctor ‘s advice and submit the claim papers for reimbursement. It is further alleged by the complaint that he submitted claim form duly completed alongwith hospital treatment record with the op for reimbursement alongwith  covering letter dt. 20.02.2016, and again on 2.03.2016 and 2.06.2016 . It is further stated by the complainant that in the second week of April 2016 one Ravinder Singh an authorized investigator visited his residence who verified his Identity. It is also stated by the complainant that as per his demand he provided him the copy of Aadhar Card, Pass Book and also signed pre-drafted no- objection letter  authorizing him to get any information regarding his treatment from Sir Ganga Ram Hospital. It is alleged by the complainant that even after passing of seven months of lodging the claim Op failed to settle his claim and as such he delivered by hand legal notice Dt. 4.07.2016 to the Insurance co. but the same was not replied by the Op Insurance co. nor the claim was settled by it. This act of OP amounts to deficiency in services. Hence this  complaint.

Complaint has been contested by the OP. It denied any deficiency in services on his part. Para no. 3 and 4 of the preliminary objection of the written statement are relevant and are reproduced as under:-

1. That the answering opposite party has been duly informed by the OP No.2 that the claim of the complaint has been assessed under the terms and conditions of the policy and as per the policy terms and conditions the amount of Rs. 33008/- is payable to the complainant and the said amount has been transferred into the bank account of the complainant through IFCI.
2. That since the claim payable to the complainant under the terms and conditions of the policy has been duly paid to the complainant; the present complaint is liable to be dismissed.

Both the parties have filed their evidence by way of affidavit.

We have heard the arguments advanced at the bar and have perused the record .

During the course of arguments, it was stated by the complainant  that  during the pendency of the present complaint the Op Insurance Co. had made him the  payment twice , once for a sum of Rs. 33,008  and secondly for a sum of Rs. 13,245/-  against his claim . It is also stated by the complainant that the Insurance co. had denied the cashless facility to him arbitrarily and settled his claim and made him the payment only after he approached this Forum, hence he is entitled for compensation against the mental agony he suffered and litigation expenses.

  The Ld. counsel for the OP had contended that as the payment has been made to the complainant against his claim by the OP insurance co. the present compliant should be dismissed.

In view of the above, we are of the considered opinion that the OP Insurance co. had made the payment to the complainant only after he approached this Forum and did not even bother to reply to the legal notice sent by him before filing of the case. The delay in settling the claim of the complainant by OP Insurance Co. amounts to deficiency in services on its part. We therefore hold OP Insurance Co. liable for deficiency in service and direct it as under:-

Pay to the complainant a sum of Rs. 20,000/- on account of mental agony suffered by him which will also include cost of litigation.

The order shall be complied with within 30 days of the receipt of the copy of the order. If the said amount is not paid by the OPs within a period of one month from the date of receipt of this order, the same shall be recovered by the complainant along with simple interest at the rate of 10% per annum from the date of this order till recovery of the said amount of Rs. 20,000/–. This final order be sent to server (www.confonet.nic.in ). A copy each of this order each be sent to both parties free of cost by post.

Pronounced in open Forum on ........................

 

(S K SARVARIA)

 PRESIDENT

 

                                              (H M VYAS)                                     (NIPUR CHANDNA)

                                               MEMBER                                                  MEMBER