DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, NORTH-WEST

       GOVT. OF NCT OF DELHI

      CSC-BLOCK-C, POCKET-C, SHALIMAR BAGH, DELHI-110088.

CC No: 1046/2014

D.No._____________________                      Dated: ________________

IN THE MATTER OF:

KAUSHLENDER OJHA S/o SH. MURTI OJHA,

R/o C-394, SARASWATI VIHAR,

PITAM PURA, DELHI-110034.                             … COMPLAINANT

Versus

UNITED INDIA INSURANCE CO. LTD.,

(THROUGH ITS CMD),

SATYA BHAWAN, PLOT No. 36, 2^nd FLOOR,

COMMUNITY CENTRE, RING ROAD,

WAZIRPUR INDL. AREA, DELHI-110052.    … OPPOSITE PARTY

CORAM:SH. M.K. GUPTA, PRESIDENT

               SH. BARIQ AHMED, MEMBER                                          

                                                            Date of Institution: 03.09.2014

            Date of decision: 26.10.2018

SH. M.K. GUPTA, PRESIDENT

ORDER

1.       The complainant has filed the present complaint against the OP under Section 12 of the Consumer Protection Act, 1986 therebyalleging that the complainanttook a Mediclaim Policy from OP in respect of which the complainant been making payment of annual subscription from time to time and the last policy bearing no. 22700/48/13/06/00001943 which is valid from 18.09.2013 to

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          17.09.2014. The complainant further alleged that on account of emergency, due to severe pain in the stomach of the complainant, the complainant approached Jaipur Golden Hospital through emergency and remained admitted in the hospital and has taken treatment for ailment and the complainant was discharged from the hospital and the complainant raised bill in respect of the payment of the hospital for a sum of Rs.33,304/- and after receiving the same, the officials of OP informed the complainant through mail message on 02.01.2014, that the claim for a sum of Rs.31,011/- has been sanctioned, however, instead of getting the payment of the sanctioned amount, the complainant was shocked to receive a letter dated 22.01.2014 as per which OP has illegally and unlawfully declined the payment of the claim of the complainant by alleging that the case of the complainant is not falling in the category of an emergency. Thereafter, the complainant duly sent requisite letters from the hospital through which it is crystal clear that the case of the complainant is duly covered under the said policy of OP and thus the complainant is entitled to get the claimed amount from OP which documents were duly sent by the complainant to the office of OP and the complainant is entitled for the claimed amount with interest @ 24 % p.a. from the date of its become due till its realization and refusal by OP to reject the claim of the complainant amounts to deficiency in service.  

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2.       On these allegations the complainant has filed the complaint praying for direction to OP to pay the Mediclaim amount of Rs.33,304/- alongwith interest @ 24% p.a. from the date of its become due till its realization aswell as compensation of Rs.25,000/- for causing harassment, mental agony, conveyance etc. and tension and has also sought a sum of Rs.11,000/- towards litigation cost.

3.       OP has been contesting the complaint and has filed reply. In the reply, OP submitted that as per the terms & conditions of the policy the complainant is not entitled to get any claim and the present complaint is not maintainable and liable to be dismissed. OP further submitted that the complainant was insured vide Family Medicare Policy bearing no. 222700/48/13/06/00001943 for the period from 18.09.2013 to 17.09.2014 from OP for Mediclaim in the name of the complainant on certain terms & conditions and after receiving the claim of the complaint OP scrutinized the claim documents and found that the patient Ms. Kaushlender Ojha was admitted in Jaipur Golden Hospital on 30.12.2013 and diagnosis as case of Acute resolving appendicitis erosive gastropathy-H-pylori +ve and UGL endoscopy and as per the available document and procedure does not warrant hospitalization and the admission was primarily for diagnostic and evaluation purpose only. OP further submitted

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          that treatment can be done under OPD procedure and the claim is denied under exclusion 4.10 of policy terms & conditions and the exclusion 4.10 is “Charges incurred at hospital or nursing home primarily for diagnosis, X-Ray or laboratory examination or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at a hospital/nursing home” and duly informed the complainant about repudiation of the claim vide letter dated 22.01.2014.

4.       The complainant filed rejoinder and denied the submissions of the OP and submitted that the OP has taken a false plea.

5.       In order to prove his case the complainant filed his affidavit in evidence. The complainant also placed on record copy of policy for the period from 18.09.2013 to 17.09.2014 issued by OP, copy of discharge summary sheet issued by Jaipur Golden Hospital, copy of e-mail communication dated 02.01.2014, copy of letter dated 17.02.2014 issued by OP, copy of letter dated 22.01.2014 sent by OP to the complainant and copy of legal notice dated 06.06.2014 sent by the complainant through his counsel to OP by speed post.

6.       On the other hand, Sh. Raj Kumar Sirova, Divisional Manager of OP filed his affidavit in evidence.OP also filed copy of letter dated 22.01.2014 and copy of insurance policy. OP also filed written arguments.

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7.       This forum has considered the case of the complainant as well asOP in the light of evidence and documents placed on record by the complainant. The case of the complainant has remained consistent and there is nothing on record to disbelieve the case of the complainant. The documents and evidence of the parties shows that the complainant was diagnosed Acute Resolving Appendicitis Erosive Gastropathy-H-Pylori +veand UGL endoscopy and was admitted in the hospital on 30.12.2013 and was discharged on 02.01.2014 from the hospital and hospital charges & bills to the tune of Rs.33,304/- were paid by the complainant. OP cannot submitted that admission in the hospital for the treatment of the complainant with respect to diagnose was not necessary and OP is not justified in contending that the complainant’s claim is covered under exclusion clause 4.10. This Forum is of opinion that the ailment/disease of the complainant is not covered under clause 4.10 of the policy and OP has wrongly denied the claim. Thus, OP is held guilty of deficiency in service.

8.       Thus, holding guilty for the same, we direct the OP:

ii) To pay to the complainant an amount of Rs.20,000/- as compensation for harassment and mental agony suffered.

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9.      The above amount shall be paid by the OP to the complainant    within 30 days from the date of receiving of this order failing which OP shall be liable to pay interest on the entire awarded amount @ 10% per annum from the date of receiving of this order till the dateof payment. If OP fails to comply with the order within 30 days from the date of receiving of this order, the complainant may approach this Forum u/s 25 of the Consumer Protection Act, 1986.

10.  Let a copy of this order be sent to each party free of cost as per regulation 21 of the Consumer Protection Regulations, 2005. Thereafter file be consigned to record room.

Announced on this 26^thday of October, 2018.

BARIQ AHMED                                                                           M.K. GUPTA

  (MEMBER)                                         (PRESIDENT)

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