Delhi

New Delhi

CC/436/2015

Akshay Kumar Maurya - Complainant(s)

Versus

United India Insurance Company ltd - Opp.Party(s)

02 Aug 2019

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.436/2015                                          Dated:

In the matter of:

Akshaya Kumar Maurya,

S/o Sh. Buddha Priya Maurya,

R/o 7066, B-10,

Vasant Kunj, New Delhi-70.

 

            ……..COMPLAINANT

VERSUS

1.   United India Insurance Co. Ltd.

          Through its Manager/Authorized Signatory,

          Having office at DO 1, 60, Janpath,

           New Delhi-01.

 

2.     Medi Assist India TPA Pvt. Ltd.,

Through its Manage/Authorized Signatory,

Having its 47/1 Sri Krishna Arcade,

1^st main Ninth Cross, Sarakki Industrial layout,

JP Nagar, Third Stage, Bangalore-560078.

 

Opposite Parties.

                

NIPUR CHANDNA, MEMBER

 

ORDER

       

The complainant has filed the present complaint against the OPs under section 12 of Consumer Protection Act, 1986.  The gist of the complaint is that in the month of September 2001, the complainant purchased  a mediclaim policy   bearing No.040100/48/12/06/00002905 from OP-1 and the same policy was renewed by him from time to time, currently through the OP-2 TPA of OP-1.   In the month of April 2013, due to acute abdominal pain and vomiting  the complainant   was  admitted  to Institute of Liver & Billary Science on 9.4.2013.  Where the complainant was given treatments of Acute pancreatitis, severity: mild (CTSI: 5/10) Etiology:. The complainant incurred a sum  of Rs.1,43,735/- for his treatment.

2.     After discharge from hospital, complainant lodged his  claim with OPs for reimbursement along with  all the original bills/copies and discharge certificate. The OP-1 through its TPA i.e. Op-2 repudiated his claim on the ground that “according to policy terms and conditions the alcohol related ailment are not payable, hence this claim is denied under exclusion clause  4.8” and also stated that “the complainant is chronic alcoholic and pancreatitis is directly related to alcohol intake”.   After repudiating the claim of the complainant  by both the OPs, in the month February/May 2014 he preferred his claim  to the CRM Grievance Cell United India Insurance Co. Regional Office, New Delhi  and United India Insurance Co. Regional Office, New Delhi respectively but all in vain, complainant, therefore, approached this Forum for redressal of her grievance.

3.     Notice of the complaint was sent to both the OPs. None appeared on behalf of both the OPs, therefore, they were ordered to be proceeded with ex-parte vide order dt. 10.2.2016.  

4.     Complainant has filed his evidence by way of affidavit,

5.     We have heard argument advance at the Bar and have perused the record.

6.     From the un-rebutted testimony of the complaint and documents placed on record, we are convinced that the story put forth by the complainant is true. 

 

7.     Bare perusal of the treatment record proves that the complainant was admitted in the hospital and had undergone the treatment and paid the entire bills raised by the hospital, despite the fact that he was covered under the mediclaim policy issued by OP-1.  Non-settlement of the claim of the complainant by the OP-1 amounts to deficiency in services. We, therefore, hold the OP-1 guilty of deficiency in service and direct it as under:

 

i).  Pay to the complainant a sum of Rs.1,43,735/-  along with interest @  9% p.a. from the date of institution of this complaint i.e.  8.07.2015  till payment.

ii)   Pay to the complainant a sum of Rs.10,000/- as compensation towards harassment, mental agony and pain.

 

ii)   Pay to the complainant a sum of Rs.10,000/- as litigation cost.

 

 

A copy each of this order each be sent to both parties free of cost by post. Orders be also sent to www.confonet.nic.in. File be consigned to record room.

Pronounced in open Forum on 02/08/2019.

 

 

(ARUN KUMAR ARYA)

PRESIDENT

                        (NIPUR CHANDNA)                                           (H M VYAS)

                          MEMBER                                                         MEMBER