DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi- 110016
Case No.419/12
Kamal Kumar Agarwal
RZ-40, Shiv Mandir Marg
Raj Nagar, Palam Colony
New Delhi-110045. .…Complainant
VERSUS
United India Insurance Co. Ltd.
18, Kanchanjunga, Barakhamba Road
New Delhi-110001. ….Opposite Party
Coram:
Ms. Monika A Srivastava, President
Ms. Kiran Kaushal, Member
Present: None.
Present: OP is ex-parte
ORDER
Date of Institution:19.10.2012
Date of Order : 24.07.2024
President: Ms. Monika A Srivastava
Complainant has filed the present complaint seeking refund of Rs.32,780/- for expenditure occurred on his treatment/hospitalisation; pay Rs.50,000/- as compensation for harassment, inconvenience, frustration and mental agony suffered by the complainant and pay Rs.20,000/- towards costs and other expenses. OP is United India Insurance Co. Ltd.
- It is stated by the complainant that along with him, his wife and three children were beneficiary/insured by OP’s ‘Family Medicare Policy’ bearing policy No.040200/48/10/06/00004624 for the period 14.03.2012 to 13.03.2013 and the insured amount is Rs.5,00,000/- and complainant had paid premium of Rs.11,547/-. Copy of premium paid is annexed as annexure A.
- It is stated that the complainant and his family was insured since 2007 and it is not the first year policy. On 07.05.2012 complainant after noticing that the colour of his urine was looking reddish, therefore he rushed to nearby Hospital where the stone in right kidney was diagnosed. Thereafter he visited Sir Ganga Ram Hospital New Delhi where after various tests, stone in right kidney was confirmed. On 18.06.2012, complainant was admitted for surgical removal of stone of right side kidney and thereafter complainant was discharged on 18.06.2012 from the hospital. Copy of discharge summary is annexed as annexure B.
- It is stated that before admission in the hospital complainant telephonically informed the OP regarding his hospitalisation. It is further stated by the complainant that in respect of his treatment/surgery and hospitalisation, the complainant submitted a claim of Rs.32,780/- in reference of expenditure occurred on account of his treatment/hospitalisation reimbursement request is annexed as annexure C. But TPA of Insurance Co. arbitrarily repudiated the claim of the complainant by stating the claim for removal of stone in the first year policy is excluded, which is wrong as the insurance policy is not first year policy but complainant his family was insured since 2007 till date by holding medi-claim policy.
- The OP is exparte despite due service. Complainant has filed his evidence affidavit and written submissions. This Commission has gone through the entire material placed on record. It is seen that the complainant has taken policy of insurance in the year 2005 to 2006 from Royal Sundaram, for the year 2007 to 2008, it was insured by United India Insurance Co., for the year 2009 to 2010 it was insured by United India Insurance Co., for the year 2010 to 2011 it was insured by Bharti AXA General Insurance Co. and for the year 2012 to 2013 , it was insured by United India Insurance Co. Ltd. The policy document placed on record pertaining to the OP also does not record any previous policy number. As is evident, the complainant has been changing different companies for his insurance and therefore the claim raised by him in the year 2012 has been repudiated by the OP being a renal case in the first year of policy and which as per the terms of the policy cannot be provided in the first two years of the policy.
The Hon’ble Supreme Court in the matter of SGS India Limited vs Dolphin International AIR 2021 SC 4849 has held the following
“The onus of proof that there was deficiency in service is on the complainant. If the complainant is able to discharge its initial onus, the burden would then shift to the Respondent in the complaint.”
It is therefore, upon the complainant to initially discharge its onus to prove that there was deficiency in service on the part of OP. This Commission has gone through the pleadings and documents filed by the complainant and find that complainant has not been able to discharge this onus. Therefore, the present complaint is dismissed being devoid of any merits.
Copy of the order be given to the parties as per rules. File be consigned to the record room. order be uploaded on the website.
