Haryana

StateCommission

A/257/2015

INDERJEET YADAV - Complainant(s)

Versus

UNITED INDIA INSURANCE CO. - Opp.Party(s)

IN PERSON

27 Oct 2016

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

         

                                                         First Appeal No.257 of 2015  

Date of Institution: 18.03.2015                                                              Date of Decision: 27.10.2016

 

Inderjeet Yadav age 31 years, resident of 52-B, Mianwali Colony, Sector-12, Gurgaon 1220091.

…..Appellant

Versus

1. United India Insurance Company Limited, Plot No.25, MCH No.8-2-334, Azam colony, road No.03, Banjara Hills, Hyderabad.
2. Famil Health Plan (TPA)_ Plot No.8, 2^nd Floor, Retail Business Center, Nangal Raya, Opposite Janakpur ‘D Block’ New Delhi-46.

…..Respondents

 

CORAM:             Mr. R.K.Bishnoi, Judicial Member.

                             Mrs. Urvashi Agnihotri, Member.                                                                                                                                        

Present:              Shri Inderjeet Yadav appellant in person.

Shri P.S.Saini, Advocate counsel for the respondent No.1.

Respondent No.2 was dispensed with vide order dated 12.08.2015.

 

                                                   O R D E R

R.K.BISHNOI, JUDICIAL MEMBER:

It was alleged by the complainant that he obtained medi-claim policy from the opposite party No.1 (O.P.)/respondent No.1 for Rs. One lac valid from 07.11.2009 to 06.11.2010. His wife suffered fromenteric fever in May, 2010 and received treatment on 19.05.2010 and 23.05.2010 at Yadav Hospital, but, she could not recover. She also remained admitted at above said hospital from 30.05.2010 till 03.06.2010. He spent Rs.11700/-+3786/-=15486/- on her treatment.  Information was also given to O.P. Nos.1 and 2. On 11.06.2010  claim was submitted with O.Ps., but, that was repudiated vide letter dated 16.07.2010. Thus there was deficiency in service on the part of the O.Ps.

2.       Only O.P. No.1 filed reply controverting his averments and alleged that he did not provide receipts about the amount claimed and other documents were not genuine. On investigation, it was found that hospital was not registered hospital.  There was no proper admission register. There was over writing and manipulations in the register. The claim of the complainant was rightly rejected vide letter dated 16.07.2010, so he was not entitled  for claim of Rs.15,486/-.  Thus there was  no deficiency in service on it’s part. Objections about  maintainability of complaint, pre-mature etc. were also raised and requested to dismiss the complaint.

3.      As O.P.No.2 was failed to file reply within stipulated period, thus its defence was struck off on 07.12.2010.

4.      After hearing both the parties, learned District Consumer Disputes Redressal Forum, Gurgaon (In short “District Forum”) dismissed the complaint vide ordered dated 09.02.2015.

5.      Feeling aggrieved therefrom, complainant has preferred this appeal on the grounds that District Forum did not appraise law and facts properly. When amount was spent on her treatment, so the insurance company was liable to pay the amount.  Impugned Order dated 09.02.2015 is altogether against the law and the same be set aside.

6.      Arguments heard. File perused.

7.      Learned counsel for the appellant-opposite party vehemently argued that complainant did not provide receipt and proper documents for the amount claimed, so he is not entitled for any claim.

8.      This argument is devoid of any force. It is not disputed that he obtained medi-claim policy from the O.Ps. Perusal of the file shows that as per bills, he has spent Rs.15,486/-. There is no reason to disbelieve them. They were ignored by learned District Forum without sound principles of law. Hence, the appeal is allowed and  opposite party No.1 is directed to pay Rs.15,000/- as per bills + 4,000/-=Rs.19,000/- (in lump sum) to complainant within 45 days from today, failing to which O.P. No.1 will be liable to pay interest @ 12% per annum from the date of filing of the complaint till realization.

 

October 27th, 2016     Urvashi Agnihotri                                R.K.Bishnoi,                                                               Member                                              Judicial Member                                                         Addl. Bench                                        Addl.Bench                

S.K.