2^nd Additional Bench

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

PUNJAB

First Appeal No.150 of 2017

Date of Institution: 02.03.2017

Date of Reserve : 17.08.2017

Date of Decision : 04.09.2017

Darshan Singh Reehal aged 70 years son of Late S. Harbans Singh,

resident of 811, Phase II, Urban Estate, Focal Point, Ludhiana.

…..Appellant/Complainant

Versus

1. Cholamandlam MS General Insurance Company Limited,

Registered Office : Dare House, 2^nd Floor, N.S.C. Bose Road,

Chennai-600001.

2. Cholamandlam MS General Insurance Company Limited,

Branch Office : 132/3, 2^nd Floor, K.L.Plaza, Opp. DIG

Residence, Rani Jhansi Road, Civil Lines, Ludhiana.

……Respondent/opposite parties

First Appeal against the order dated

09.01.2017

of

the

District

Consumer

Disputes Redressal Forum, Ludhiana.

Quorum:-

Mr. Gurcharan Singh Saran, Presiding Judicial Member

Mr. Rajinder Kumar Goyal, Member

Present:-

For the appellant : Sh.D.S.Reehal, in person

For the respondents : Sh.Punit Jain, Advocate

GURCHARAN SINGH SARAN, PRESIDING JUDICIAL MEMBER

ORDER

The appellant/complainant (hereinafter referred to as

‘complainant’) has filed the present appeal against the order dated

09.01.2017 passed by the District Consumer Disputes Redressal

Forum, Ludhiana (hereinafter referred to as ‘District Forum’) in

Consumer Complaint No.211, dated 16.03.2016, vide which the

complaint filed by the complainant was partly allowed with a direction

to the opposite parties to pay a sum of Rs.85,000/- to the complainant

First Appeal No.150 of 2017

in terms of the policy. He is also entitled to the amount of Rs.33,520/-

It was ordered to comply with the order within 30 days.

2.

Complaint was filed by the complainant under Section 12

of the Consumer Protection Act, 1986 (hereinafter referred to as ‘the

Act’) on the averments that he purchased a Chola Swasth Parivar –

Pearl Policy from the opposite parties distributed by Central Bank of

India as Corporate Agent of the Company meant for ex-employees of

the Bank on 14.08.2015, renewed on 14.08.2013, 14.08.2014 and

14.08.2015. Smt. Harpal Kaur Reehal wife of the complainant is also

co-assured in the said policy. She was admitted in Fortis Hospital,

Ludhiana on 19.10.2014. After pre-authorization clearance for

cashless facility she was operated upon for total knee replacement on

20.10.2014. When she was convalescencing well in the Ward, she

suffered from breathlessness and ECG changes, therefore, she had

to be re-shifted to ICU for the treatment. She was discharged from

the hospital on 28.10.2014 and a bill of Rs.3,62,458/- was paid which

included treatment of breathlessness of Rs.33,520/-. However, the

Insurance Company cleared Rs.1,00,000/- with stipulation of 15% as

co-payment and rest of the amount was not paid to him. The sum

insured was Rs.5,00,000/-. They have covered it under term surgery

for which a maximum of Rs.1,00,000/- is admissible but total knee

replacement is not covered in the surgery which comes under the

purview of implant. The claim was repudiated vide letter

No.A737349B dated 22.01.2015 followed by their detailed letter dated

24.02.2015. A complaint was filed before the Ombudsman and after

hearing the Ombudsman passed an award of Rs.33,520/-. Alleging

deficiency in service, complaint was filed before the District Forum

First Appeal No.150 of 2017

seeking direction against the opposite parties to pay claim of full

amount of total knee replacement as cost of implant.

3.

Complaint was contested by the opposite parties by filing

their written reply stating therein that wife of the complainant was

insured with Chola Swastik Parivar for health cover of a maximum of

Rs.5,00,000/- vide policy No.2855/00100274/000/02 for the period of

14.08.2014 to 13.08.2015 alongwith the terms and conditions. The

claim was received from the complainant which was duly registered

vide Claim No

Click Here to Read the rest of this document