- (1.) THIS is insurer's appeal under Section 15 of the Consumer Protection Act, 1986 against the order dated 18.5 2010 passed by the District Forum, Haridwar in consumer complaint No. 60 of 2009. Bythe order impugned, the District Forum has allowed the consumer complaint arid directed the opposite parties to pay the insured amount to the complainant and also to pay sum of Rs. 5,000 towards damages.
(2.) BRIEFLY stated, the facts of the case as mentioned in the consumer complaint, are that the complainant had purchased a Hospitalisation and Domiciliary Hospitalisation Benefit Policy (Mediclaim Policy) from the opposite party No.l - The New India Assurance Company Limited (appellant before this Commission) for himself, his wife and son for assured sum of Rs. 2,00,000 each. The policy was valid for the period from3.1.2008 to 2.1.2009. Prior to the said policy, the complainant had also previously purchased the same policy, in the last year, which was valid from 3.1.2007 to 2.1.2008. In the year 2008, the complainant suffered from heart ailment and on 18.9.2008, he. was admitted in Indraprastha Apollo Hospital, New Delhi, where his angiography was done on 22.9.2008. The complainant was discharged from the hospital on 25.9.2008. The complainant informed the Insurance Company about his treatment. The Insurance Company asked the complainant to submit the claim form alongwith original bills and treatment papers. On 11.11.2008, the opposite party No.2 asked for certain papers from the complainant. The complainant sent the papers as desired by the opposite party No.2. As per the policy, the complainant was not to pay the expenses incurred on his treatment and the expenses were to be paid by the Insurance Company to the concerned hospital, but there was no tie -up between the Insurance Company and Indraprastha Apollo Hospital, New Delhi and, as such, the facility of cashless was not provided by the said hospital to the complainant The complainant asked for settlement of his claim, which was repudiated by the opposite party No.2 on the ground that the complainant had been suffering from the treated disease for the last 15 -20 years and hence the claim is not payable. Alleging deficiency in service on the part of the opposite -parties, the complainant filed a consumer complaint before the District Forum, Haridwar.
(3.) THE Insurance Company filed written statement before the District Forum and pleaded that the liability to settle the claim is that of the opposite party No.2 and it was merely an agent of the opposite party No.2. The documents submitted by the complainant, were remitted to the opposite party No.2 and it was further pleaded that the liability, if any, is that of the opposite party No.2. The opposite party No.2 respondent No.2 also filed written statement before the District -Forum and pleaded that as per the discharge summary of the complainant, he had been suffering from the disease treated for the last 15 -20 years and hence the claim is not payable.;