IN THE DELHI STATE CONSUMER DISPUTES REDRESSAL COMMISSION Date of Institution: 05.11.2016 Date of Hearing: 01.05.2023 Date of Decision: 31.10.2023 FIRST APPEAL NO.- 557/2016 IN THE MATTER OF M/s ORIENTAL INSURANCE CO. LTD., Head Office:

A-25/27, Asaf Ali Road, New Delhi – 110002.

Also at:

Division Office:

23/23-B EMCA House, Ansari Road, Daryaganj, New Delhi-02.

(Through: Mr. Bhupesh Kumar Chandna, Advocate)

…Appellant VERSUS MR. VISHESHWAR SHRIVASTAV, S/o Mr. G.P. Shrivastav, R/o J-22, Saket, New Delhi.

(Through: Respondent in Person)

… Respondent CORAM:

HON’BLE JUSTICE SANGITA DHINGRA SEHGAL (PRESIDENT)

HON’BLE PINKI, MEMBER (JUDICIAL)

Present: Ms. Vedangi, proxy counsel for Mr. Bhupesh Kumar Chandna, counsel for Appellant.

None for the Respondent.

PER: HON’BLE JUSTICE SANGITA DHINGRA SEHGAL, PRESIDENT JUDGMENT

1. The facts of the case as per the District Commission record are:

“The complainant has filed this complaint before this forum challenging partial repudiation of the claim of his mediclaim policy. The Complaint is that he purchased an Happy Family Floater Policy Schedule No.271600/48/2012/1173 in his and his family's name consisting of his wife Mrs. Pratima Shrivastav and his son Ashutosh Shrivastav from M/s Oriental Insurance Company Ltd (OP-2) in the year 2009 for the sum of Rs.8 lacs. It is also the case of the complainant that he has been paying annual premium for the said policy on time.

The wife of the complainant namely Mrs Pratima Shrivastav, who is an AVR patient, was diagnosed with endometrial thickening (Endomertosis) in the uterus and was advised to undergo D&C surgery for the same. Pursuant thereto the complainant opted for Max Hospital, Saket for the said surgery and wife of the complainant was admitted in the hospital for the surgery on

14.11.2012.

The complainant, as per the procedure filled up the pre hospitalization form so he can avail the cashless benefit. However, the said cashless benefit was denied and complainant was directed to file the claim with the OP-2 after the surgery.

On 14.11.2012 the wife of the complainant was admitted in the hospital whereby she was operated upon on the same date. The patient was discharged from the hospital on 22.11.2012 and an amount of Rs.49,073.46 was spend in the surgery. Thereafter the complainant filed the claim form and submitted the same on the same date with M/s Vipul MedCorp TPA Pvt.Ltd (OP- 1), which is IRDA approved Third Party Administrator for processing the claim against OP-2 The claim was duly acknowledged but there was no response by either of the Ops for the next 3 months. Thereafter on 8th July, 2013 the complainant received the discharge voucher from OP-1 whereby deduction of Rs.17,534/- was made from the amount claimed for (Rs.49.073.46). OP-1 also sent the draft format letter stating therein that complainant accepts the amount of Rs.31,539/- after deduction in full satisfaction and final settlement of all claims present or future. Being not satisfied with the said partial repudiation of the claim, the complainant filed this complaint before this forum.

Complainant further states that as the OP-2 did not provide cashless facility, he had made payment to the hospital through his credit card and he has incurred additional interest @ 2.5% per month which came to Rs.4,717/- that he has paid to credit card company.

Hence the complainant has filed this complaint seeking following reliefs:-

“a) Direct the respondent No.1 & 2 to jointly or severally pay Rs.49,073/- for the amount paid at Max Hospital Saket with interest @24% till the date of payment ;and b) Direct the respondent NO.1 &2 to jointly or severally reimburse Rs.4712/- paid to the credit card till date and further interest till the date of payment; and c) Direct the respondent NO.1 & 2 to jointly & severally pay Rs.10,000/- for monetary agony and exemplary damages for not giving cashless hospitalization facility; and d) Any other relief in favour of complainant and against the respondents.”

2. The District Commi