State Consumer Disputes Redressal Commission
United India Insurance Co. Ltd., vs 1. Dr. Indra S/O. Rupchandji Ostwal on 9 February, 2011
F.A.No.:218-10
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STATE CONSUMER DISPUTE REDRESSAL COMMISSION,
MUMBAI, CIRCUIT BENCH AT AURANGABAD.
Date of filing: 01.04.2010
Date of Order: 09.02.2011
FIRST APPEAL NO. 218 OF 2010
IN COMPLAINT CASE NO. 60 OF 2009
DISTRICT CONSUMER FORUM: HINGOLI.
United India Insurance Co. Ltd.,
Through its Divisional Manager,
Aurangabad Division, having office at
Osmanapura Circle, Station Road, Aurangabad. ... Appellant
//VERSUS//
1. Dr. Indra s/o. Rupchandji Ostwal
R/o. Doctor Colony,
Nr. Bus Stand, Parbhani.
2. Sow. Anita Indra Ostwal
R/o. As Above.
3. The Authorized Signatory,
M.D. India Health Care Services (TPA) Pvt. Ltd.
Regional Office, 51/A, 2nd Floor,
Dr. Bhivapurkar Road, Dhantoli, Nagpur. ...Respondents
... Respondent
Coram : Shri.S.G.Deshmukh, Hon`ble Presiding Judicial Member.
Mrs. Uma S.Bora, Hon`ble Member.
Shri. K. B. Gawali, Hon'ble Member.
F.A.No.:218-10 2 Present: Adv. Shri. Sunil Thite holding for Adv. Shri. S. S. Rathi for appellant.
Adv. Smt. Z. M. Surti holding for Adv. Smt. Asha Rakh for respondent :: ORAL ORDER ::
Per Shri S.G.Deshmukh, Hon`ble Presiding Judicial Member
1. The present appeal is filed by the New India Assurance Company Limited, against the Judgment & Order dated 24.02.2010 in complaint case No. 60/2009 passed by District Consumer Forum, Hingoli.
2. Respondent/complainant's case before the Forum is that, they had obtained Joint Medi-Claim Policy for the period of one year from 14.08.2006 to 13.08.2007. Thereafter they have renewed the policy for the next year and then for 14.08.2008 to 13.08.2009. Sum assured for both the insured was Rs.1,25,000/- each. It is alleged that the Respondent No.2 was suffering from illness in uterus and accordingly she consulted at Patil Hospital, Parbhani and after giving various investigations she was diagnosed as having "multiple fibroid with uterus". She was admitted in Galaxy Hospital at Pune and she has undergone surgery of hysterectomy on 07.01.2009. She was discharged from the hospital on 08.01.2009. It is alleged that she incurred expenditure of Rs. 95,341/- for the hospital including surgery. It is alleged that she approached the appellant. The F.A.No.:218-10 3 appellant paid her Rs. 25,000/- only on 23.03.2009. Complainant accepted the amount under protest. Thereafter complainant made enquiry about balance amount, lastly she approached the Forum.
3. The present appellant appeared before the Forum and resisted the claim. It is contended that they had made the payment of Rs. 25,000/- as per terms and conditions of the policy. According to them only 20 % of the sum assured is payable for hysterectomy. The 20 % of sum assured Rs. 1,25,000/- comes to Rs. 25,000/-.
4. Forum below after going through the papers and hearing the parties partly allowed the complaint and directed appellant to pay Rs.25,000/- with the interest @ 9 % p.a. from 23.03.2009. Forum also directed to pay Rs. 500/- towards mental agony and Rs. 500/-
towards the cost.
5. Being aggrieved by the said Judgment and Order Insurance Company came in appeal.
6. Notice was issued to the respondent. The learned counsel Smt. Asha Rakh, appeared for the respondent. We heard learned counsel Shri. Sunil thite holding for Adv. Shri. S.S. Rathi for appellant and Smt. Z. M. Surti holding for Adv. Smt. Asha Rakh for the respondent. We perused the papers. There is no dispute about the policy obtained by complainant for sum assured Rs.1,25,000/- for each policy holder. The policy was joint medi-claim policy for both the complainant. There is also no dispute that the complainant no.2 F.A.No.:218-10 4 had undergone hysterectomy on 07.01.2009. There is also no dispute that the complainant was admitted in Galaxy Hospital at Pune. It is the contention of the respondents that they were required to expenses of Rs. 95,341/-. There is also no dispute that the appellant paid Rs. 25,000/- to the respondents. Only it is the contention of the appellant that 20% of the sum insured is payable for hysterectomy. We perused the policy in question. The policy mentioned that, for Hysterectomy - 20% of the sum insured subject to a Maximum of Rs. 50,000/- which to be paid.
7. In the instant case, sum assured is Rs.1,25,000/-. 20 % of sum assured comes to the tune of Rs. 25,000/-. As per clause-C for hysterectomy 20 % of S. I. subject to a maximum of Rs. 50,000/- is to be paid. Forum has rightly considered this aspect and rightly passed the order that appellant is to pay Rs. 25,000/- as balance amount. We do not find any illegality in the order. We pass following order.
O R D E R
1. Appeal is dismissed summarily.
2. Appellant to pay the amount of Rs. 1,000/- towards cost.
(K. B. Gawali) (Mrs.Uma S. Bora) (S. G. Deshmukh)
Member Member Presiding Judicial Member
Kalyankar
F.A.No.:218-10
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