State Consumer Disputes Redressal Commission
The New India Ass Co Ltd vs Vallabhbhai J Patel on 4 September, 2021
Details DD MM YY
Date of Judgment 04 09 2021
Date of filling 04 04 2016
Duration 00 05 05
IN THE CONSUMER DISPUTES REDRESSAL
COMMISSION, GUJARAT STATE AT AHMEDABAD.
Court-2
APPEAL NO. 234 of 2016
The New India Assurance Co. Ltd.
1st floor, kalayan Chamber,
Station Road, Bilimora ...Appellant
Vs.
Vallabhbhai Jivaji patel,
Residing at : Opp. Parsi Agiari,
River street, Chikhli,
Dist: Navsari ...Respondent
Appearance: Ld. Advocate H.G. Mazmundar
For the appellant
No one remain present on behalf of
the respondent side
Coram : Shri M. J. Mehta Judicial Member
Order by Shri M.J.Mehta, Judicial Member
1. Being aggrieved and dissatisfied with the judgment and order dated 15.02.2016 passed by the Learned District Forum, Navsari in Complaint Case No.114 of 2015.
2. The appellant has preferred instant appeal on the grounds that the impugned order is arbitrary, perverse and is bad in law. The parties will be referred to as per their original nomenclature for the sake convenience.
Richa A-16-234 Page 1 of 63. The brief facts of the case are as under: The Complainant and his wife has obtained the policy regarding medi-claim the number of policy is 230901/34/13/2500000976 for the period of 05.01.2014 to 04.01.2015 for sum insured of Rs. 100,000/- and bonus amount is 40,000/-. During the period when insurance policy was in force, Due to chest pain and panic the complainant had to undergo necessary treatment at Banks Heart institute for the period from 20.03.2014 to 31.03.2014 at Surat and required operation had been done.
Necessary intimacy was given after the completion of the treatment of the complainant, all the original documents were handed over to the TPA of opponent. All the original documents have been in the possession of opponent since then. About Rs. 1,79,462/- under the complainant medi-claim policy of Rs. 1,40,000/- was legally entitled. Instead of Rs. 1,79,462/- Rs. 58,600/- were transferred in the account of the complainant and that was deposited from the NIFT system without any notice or consent the money were deposited in the bank account. However, the complainant did not provide any information on the basis on which they settled the claim.
4. Thereby, insurance company has preferred the present the appeal against order of the Learned Trial Forum has allowed the claim of Rs. 81,400/- with 9% interest as against till it is realization.
Richa A-16-234 Page 2 of 65. Learned Advocate Mr. Mazumdar on behalf of the appellant side has submitted before me that Learned Trial Forum has granted prayer in favor of without considering the evidence and provision of law. Hence, the order is deserves to be set aside.
6. Further Ld. Advocate submitted before me that Learned Trial Forum did not considered terms and condition of the insurance policy and passed an award which requires to be set aside.
7. Further Ld. Advocate Mr. Mazmudar submitted before me 58,600/- were sanctioned as per the policy and paid up the amount on 24.07.2014 and thereafter above 1 year and 3 months complainant has not file a complaint in time.
8. Looking to the facts and circumstances of the case the respondent served upon duly thereafter respondent is absent before the court this is vary on complaint then again notice was issued to the complainant but no one remain present on behalf of the complainant/respondent side.
9. Thereby I gone through the judgment delivered by Learned Trial Forum and documents, papers produced before me.
10. Ld. Advocate Mr. Mazmudar for the appellant submitted before me that at pg no. 52 claim was made by the complainant is not tenable in eye of law. I go through the pg no. 52 Richa A-16-234 Page 3 of 6 which is expenses incurred by the complainant side out of a bill no. 2039 dated 28.03.2014, bill no. 1468 dated 28.03.2014 Rs. 6000/-, bill no. 2049 dated 28.03.14 Rs. 8000/-, bill no. 2039 dated 28.03.2014 Rs. 2100/- are just and fair for reduction of claim.
11. Remaining all other amounts shown in the pg no. 52 are quit just fair to be entitled by complainant and that's why as according to my view the deduction shown at pg no. 52 is not accepted full as we have narrated herein above the amount Rs. 21,500/- this amount cannot be allowed and wrongly allowed by the learned Trial Forum.
12. So I am of the opinion that learned Trial Forum has allowed Rs. 81,400/- out of that amount Rs. 59,500/- entitled by complainant.
13. Thereby I came to the conclusion that Ld. Advocate for the appellant has specifically pointed out that Learned District Forum has not justified awarding full amount remaining.
14. On considering at pg no. 52 hospitalization benefit have been specifically annual narrated under the head of the table as benefit at pg no. 52 and thereby, considering terms and condition of the insurance policy maximum amount for nursing expenses has been mentioned besides this if the patient has paid up the excess amount then the actual allowable amount and thereby Richa A-16-234 Page 4 of 6 sum insured amount is look in to and accordingly all this expenses here above narrated it should be paid up but excessive payment made by the claimant is not permissible to allow and that's why that amount is deducted and thereby I came to the conclusion the amount 59,500/- compare with the table of the benefits.
15. Thereby looking to the table of benefit and case papers I came to the conclusion that maximum amount of Rs. 59,500/- amount payable to the complainant or an above in addition Rs. 58,600/- paid up to the complainant on dated 27.04.2014.
16. Thereby I am opinion that this appeal is partly allowable and order of the Learned Trial Forum is modified as under.
FINAL ORDER
i) The present appeal is partly allowed.
ii) The order of the Learned Trail Forum in Complaint No. 114/2015 dated 15.02.2016 is modified as under.
iii) Hereby complainant is entitled to Rs. 59,500/- with 7% interest from the respondent insurance company in the compliant remaining amount of the Learned Forum are confirmed.
iv) The office is hereby ordered to pay deposited amount with accrued interest on proper verification to the appellant by Account payee cheque and the cheque be handed over to the Richa A-16-234 Page 5 of 6 learned advocate for the appellant after obtaining receipt.
v) No order as to costs.
vi) Copy of the judgment be provided to the parties free of charge.
vii) Registry is directed to send copy of this judgment to the parties. Registry is directed to send a copy this judgment to the District Commission, Navsari through E-mail in PDF format for taking necessary action.
Pronounced in the open court on 4th September, 2021.
(M.J.Mehta) Judicial Member Richa A-16-234 Page 6 of 6