State Consumer Disputes Redressal Commission
The Oriental Insurance Co. Ltd. vs Poojan Garg on 3 March, 2015
Daily Order IN THE STATE COMMISSION : DELHI (Constituted under Section 9 of the Consumer Protection Act, 1986) Date of Decision:03.03.2015 First Appeal- 151/2010 (Arising out of the order dated 07.07.2009 passed in Complainant Case No. 641/2009 by the District Consumer Forum, K.G. Marg, New Delhi) The Oriental Insurance Company Ltd., Through its Divisional Office No.10, 101, LSC, Ist Floor, H-Block Market, Vikaspuri, New Delhi-18. ....Appellant Versus Poojan Garg, S/o Shri N.R. Garg, G-29/25, Sector-3, Rohini, Delhi-110085. ....Respondent CORAM Justice Veena Birbal, President Salma Noor, Member
1. Whether reporters of local newspaper be allowed to see the judgment?
2. To be referred to the reporter or not?
Justice Veena Birbal, President This is an appeal under Section 15 of the Consumer Protection Act, 1986 (in short, "the Act") against an ex-parte judgement dated 7.7.09 in Complaint Case No.641/2009 passed by District Consumer Forum, K.G. Marg, New Delhi (in short, "the District Forum") whereby the aforesaid complaint case has been allowed and appellant/OP is directed to pay following amount to the respondent/complainant:
OP will pay Rs.16,942/- to the Complainant towards the treatment of his daughter. On account of deficiency of service, mental agony and harassment, OP will pay Rs.15,000/- to the Complainant. OP will pay Rs.10,000/- towards cost of litigation.
Briefly the facts relevant for the disposal of present appeal are as under:
Respondent herein i.e. complainant before the District Forum was a Mediclaim policy holder of appellant from 17.01.08 to 16.01.2009 wherein his other family members were also covered. On 15.12.08, daughter of the respondent had got head injury due to fall from bed and was admitted in Ekansh Nursing Home where she was treated and was discharged on 16.12.08. Thereafter on 20.12.08, the respondent had submitted the claim of Rs.16,942/-to appellant through Raksha TPA Pvt. Ltd. i.e. OP-2 (not made a party in this appeal) before the District Forum for reimbursement along with necessary documents. The aforesaid TPA of the appellant i.e. OP-2 after receipt of the documents from the respondent approved Rs.14,942/- as per terms of policy after deducting Rs.2,000/- towards room rent. On 30.01.09, the TPA/Op-2 had sent a voucher of Rs.14,942/- to the respondent. The respondent after signing had sent the said voucher to TPA/OP-2 through speed post. Inspite of 2 month of sending of voucher, the respondent did not get the reimbursed amount. The respondent enquired about the status of the claim from the TPA/OP-2. The said TPA/OP-2 had sent a letter dated 26.06.2009 informing the appellant that the cheque had been returned due to incomplete address on 20.02.2009. The respondent informed the TPA/OP-2 that he had mentioned his full address in the proposal form and covering letter of the claim was also having his full address. Despite that cheque was not sent to her. It was alleged that TPA of appellant i.e. OP-2 insisted for getting correction of address from the appellant and did not send the cheque to her. The respondent alleged fault on the part of appellant and OP-2 and had filed the aforesaid complaint case before the District Forum seeking directions for payment of Rs.16,942/- towards treatment of his daughter along with compensation for harassment, mental pain and agony to her.
Ld. Counsel for the appellant has submitted that the appellant could not contest the case before the District Forum as the appellant was proceeded ex-parte. It is submitted that the respondent was entitled for a sum of Rs.14,942/- only and the said amount was also sent at her address available on the policy. However, the cheque was returned back due to incomplete address and since the appellant was not having any other address, the cheque could not be sent again to her. It is submitted that there is no fault on the part of the appellant. It is contended that Rs.2,000/- was deducted from claim submitted as under the terms and conditions of policy, respondent was not entitled for the room rent. It is contended that the impugned order is illegal and the same is liable to be set aside.
On the other hand, Ld. Counsel for the respondent has submitted that there is no illegality in the impugned order. The appellant did not come to contest the case before District Forum despite being served. It is further submitted that appellant has not filed the terms and conditions of policy to substantiate its stand that the respondent was not entitled for Rs.2,000/- towards room rent as is alleged. It is further submitted that the complete address of respondent was available with appellant despite that cheque was not sent to her. It is submitted that District Forum has observed unfair trade practice on the part of appellant on the basis of material on record. There is no illegality in the impugned order.
We have considered the submissions made and gone through the material on record.
Perusal of impugned order shows that the appellant did not appear before the District Forum despite being served and as such was proceeded ex-parte and thereafter no steps had been taken for setting aside the ex-parte proceedings by the appellant. Even in the appeal, nothing has been stated as to why the appellant did not appear before the District Forum to contest the complaint case filed against the appellant.
The stand of the appellant is that the respondent No.1 was entitled for reimbursement of Rs.14,942/- only and the cheque for the said amount was sent by its TPA/OP-2 to the respondent at the address available in the policy but the same was returned back with the noting "incomplete address" as such there was no fault on the part of appellant.
It has come on record that when respondent preferred the claim to the appellant through its TPA i.e. OP-2, the OP-2 had sent the Settlement Intimation Voucher of Rs.14,942/- to the respondent. The respondent after signing the said voucher had sent to TPA/OP-2 on 30.01.09. When the said voucher was received by the respondent, it means the complete address of respondent was available with the appellant. It is not the stand of the appellant that the said voucher was sent at some other address of respondent. In the Medical Policy Schedule, address of respondent No.1 mentioned is G-29/25, Rohini. The stand of the respondent is that when the respondent submitted documents i.e. the medical bills for Rs.16,833 along with claim, her complete address i.e. G-29/25, Sector-3, Rohini was mentioned. On the basis of said documents, Settlement Intimation Voucher was sent to respondent which in return was sent back to the TPA of appellant i.e. OP-2 after signing the same. In these circumstances, the stand of the appellant that complete address of respondent was not available is not believable. The conclusions arrived against the appellant by the District Forum are based on material on record and same are correct. Further no terms and conditions of the policy have been placed on record to show that Rs.2,000/- towards room rent has been excessively awarded to her. It has also come on record that the amount awarded has already been received by the respondent in execution petition.
In view of above discussion, no illegality or perversity is seen in the order of District Forum which calls for interference of this Commission. The appeal stands dismissed.
A copy of this order as per the statutory requirement be forwarded to the parties free of charge and also to the concerned District Forum and thereafter the file be consigned to Record Room.
(Justice Veena Birbal) President (Salma Noor) Member