Haryana

Sonipat

CC/26/2016

Manoj Gupta S/o Lal Chand Gupta - Complainant(s)

Versus

United India Insurance Co. Ltd. - Opp.Party(s)

Nitin Gupta

23 Aug 2016

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

SONEPAT.

               

                                Complaint No.26 of 2016

                                Instituted on:19.01.2016

                                Date of order:23.08.2016

 

Manoj Gupta son of late Lal Chand Gupta, resident of H.No.63P Sector 14, Sonepat.

                                            ...Complainant.

                           Versus

United India Insurance Co. Ltd. Delhi road, Sonepat through its Branch Manager.

                                           ...Respondent.

COMPLAINT UNDER SECTION 12 OF

THE CONSUMER PROTECTION ACT,1986

 

Argued by: Sh. Nitin Jain Adv. for complainant.

           Sh. KS Solanki, Adv. for respondent.

    

BEFORE-    NAGENDER SINGH………………………………………………PRESIDENT.

          SMT.PRABHA WATI……………………………………………MEMBER.

           J.L. GUPTA…………………………………………………………MEMBER.

O R D E R

            The complainant has filed the present complaint against the respondent alleging therein that he purchased a family medicare insurance policy from the respondent for himself as well as for his family and the said policy was valid and effective w.e.f. 14.12.2013 to 13.12.2014.  The complainant unfortunately was admitted in Fortis Hospital, Shalimar Bagh Delhi on 22.4.2014 for the treatment of uncontrolled diabetes mellitus, Dyshpidemia and obesity and underwent surgery on the same day, but the surgery was done for the treatment of diabetes mellitus only.  The complainant has spent Rs.3,39,400/- on his treatment on account of operation of diabetes mellitus.   The complainant informed the respondent and completed all the formalities, but the claim was denied on the pretext that the treatment of complainant was related to obesity which is not payable.  The complainant has alleged the repudiation of his claim to be wrong and illegal. So, he has come to this Forum and has filed the present complaint.

2.        In reply, the respondent has submitted that the complainant was suffering from obesity and wrongly mentioned that the complainant is suffering from diabetes mellitus.    The complainant has undergone operation of obesity with uncontrolled diabetes type II and the same does not cover under family medicare policy of the respondent.  The respondent has rightly repudiated the claim of the complainant and there is no deficiency in service on the part of the respondent while doing so and thus, prayed for the dismissal of the present complaint.

3.        We have heard the arguments of both the ld. Counsel for the parties at length and we have also gone through the entire relevant material available on the case file carefully & minutely.

4.        Ld. Counsel for the respondent has submitted that the complainant was suffering from obesity and wrongly mentioned that the complainant is suffering from diabetes mellitus.    The complainant has undergone operation of obesity with uncontrolled diabetes type II and the same does not cover under family medicare policy of the respondent.  The respondent has rightly repudiated the claim of the complainant and there is no deficiency in service on the part of the respondent while doing so.

          The complainant to prove the deficiency in service on the part of the respondent has placed on record the Annexure C-1 copy of insurance, annexure C2 repudiation letter, annexure C-3 expert opinion issued by Fortis Hospital Shalimar Bagh, New Delhi, annexure C-4 application moved by the complainant before E-Meditek, annexure C-5 legal notice, annexure C-6 postal receipt and annexure C-7 Acknowledgement.

          We have perused the document Annexure C-3 very carefully and in this document, it is mentioned that “This is to certify that the patient Manoj Gupta was admitted on 22^nd Apr. 14 in Fortis Hospital, Shalimar Bagh for treatment of uncontrolled diabetes mellitus, dyslipidemia and obesity.  He underwent surgery on the same day.  This is to state that this surgery is done for the treatment of diabetes mellitus and its associated complications when it is not being managed optimally by medical treatment.

          So, from the above document, it is proved that the surgery was done for the treatment of diabetes mellitus and not for obesity.  Thus, the repudiation of the claim by the respondent is wrong and illegal and the complainant is entitled to get the claim amount of Rs.3,39,000/- from the respondent.  Accordingly, we hereby direct the respondent to make the payment of Rs.3,39,000/- (Rs.three lacs thirty nine thousand) to the complainant  within a period of 60 days from the date of passing of this order, failing which, the above said amount shall fetch interest at the rate of 09% per annum from the date of passing of this order till realization.

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

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

File be consigned to the record-room.

 

(Prabha Wati) (JL Gupta)             (Nagender Singh-President)

Member DCDRF  Member DCDRF              DCDRF, Sonepat.

Announced:23.08.2016