NATIONAL INSURANCE CO LTD Vs. VINEET MAHAJAN
DELHI STATE CONSUMER DISPUTES REDRESSAL COMMISSION
NATIONAL INSURANCE CO LTD
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Veena Birbal, J. -
(1.) This is an appeal under Section 15 of the Consumer Protection Act, 1986 (in short, the "Act") against order dated 26.08.2016 passed by the Consumer Disputes Redressal Forum (Central) Delhi (in short, the "District Forum") in Complaint Case No.186/2015 whereby the aforesaid complaint has been allowed and appellant/OP is directed as under:
1) Pay to the complainants as sum assured of Rs.3 lacs as reimbursement of the expenses incurred for the treatment of complainant No.2.
2) Pay to the complainants a sum of Rs.30,000/- as compensation of pain and agony suffered by them.
3) Pay to the complainant a sum of Rs.5,000/- as cost of litigation.
(2.) Briefly facts relevant for the disposal of the present appeal are that a complaint under Section 12 of the Act was filed by the respondent herein i.e. the complainant before the District Forum stating therein that respondents/complainants had taken a mediclaim insurance policy from appellant/OP, which was effective from 22.07.2014. The sum assured under the policy was Rs.3,00,000/- for each of the respondents/complainants. It was stated that during the subsistence of the policy, respondent No.2/complainant No.2 was admitted in Max Hospital, Patparganj, Delhi wherein she was diagnosed as a case of Post-partum Cardiomyopathy, pneumonia with massive pleural effusion with sever sepsis with septic shock. She was admitted on 12.12.2014 and was discharged on 22.12.2014. A sum of Rs.5,51,387.87 was incurred on her treatment. Respondents/complainants had informed the appellant/OP about admission in the hospital and requested for cashless facilities, which was denied. It was stated that after discharge, a claim was filed before the appellant/OP, however, the same was not settled. Finding deficiency in service on their part, respondents/complainants filed a complaint before the District Forum seeking the total value of claim alongwith compensation and litigation costs.
(3.) Complaint was opposed by the appellant /OP by filing written statement, wherein the issuance of mediclaim policy in favour of the respondents/complainants and sum assured therein was admitted. It was stated that the policy was issued subject to its terms and conditions. It was stated that the claim was repudiated as respondent No.2/complainant No.2 was suffering from post-partum cardiomypathy, which was related to pregnancy. It was stated that such a claim was not payable under Clause 4.7 of the policy. Appellant/OP had prayed for dismissal of the complaint.;
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