STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                Date of Institution: 17.04.2017

                                                          Date of final hearing: 16.10.2023

                                                     Date of pronouncement: 05.12.2023

First Appeal No.449 of 2017

In the matter of :-

1. The Oriental Insurance Company Ltd., 4 B.P. 1^st Floor, Neelam Bata Road, Bata Chowk, NIT, Faridabad-121001 through its Divisional Manager.
2. The Oriental Medcorp TPA Pvt. Ltd., 515 Udyog Vihar, Phase V, Gurgaon, Vipul Medcorp TPA Pvt. Ltd., Plot No. 1/A, Second Floor, 19/6, Mathura Road, Faridabad-121006 through its Managing Director/Principal Officer/In charge.

Now both through their authorized signatory B.S. Ahuja, Dy. Manager, Regional Office, SCO No. 109-111, Sector-17D, Chandigarh.                                                                 ..Appellants

                             Versus

Smt. Nirmal Aggarwal wd/o Sh. Satish Aggarwal C/o M/s Aggarwal Dairy, C-45, Dabwa Sabji Mandi Chowk, NIT Faridabad.

…..Respondent

CORAM:             Naresh Katyal, Judicial Member

Argued by:-       Sh. J.P. Nahar, counsel for appellants.

Respondent already proceeded against ex-parte vide order dated 18.09.2019.

                                                ORDER

NARESH KATYAL, JUDICIAL MEMBER:

          Delay of 54 days in filing the present appeal stand condoned for the reasons stated in the application for condonation of delay.

2.      Challenge in this appeal No.449 of 2017 of appellants has been invited to legality of order dated 12.01.2017 passed by District Consumer Disputes Redressal Forum-Faridabad (In short “District Consumer Commission”) in complaint case No.155 of 2012, vide which complainant’s complaint has been allowed.

3.      Factual matrix: complainant’s husband Sh. Satish Aggarwal in continuation of previous policies, got himself and his wife (complainant) insured with OP No.1 under Floater Medi-claim Policy No.272400/48/2011/4070 valid from 23.09.2010 to 22.09.2011. Sum Assured was Rs.6,00,000/-. Premium amount was Rs.18,806/-. On 20.08.2011, husband of complainant became unconscious; was admitted in Asian Institute of Medical Science-Faridabad. His condition did not improve and he was discharged on 04.09.2011 and shifted to Niramaya Hospital-New Delhi on same day, where he expired on 13.09.2011. Initially, OP No.2 vide cashless authorization letter dated 31.08.2011 approved Rs.2,00,000/- for treatment of complainant’s husband, but application for further cash approval of Rs.5,06,566/- was denied by OP No.2 vide letter dated 04.09.2011 on ground that: sum insured exhausted, so complainant paid aforesaid amount to hospital, as well as, final bill raised by Niramaya Hospital amounting to Rs.2,21,781/-. She was busy in performing last rites of her husband and was under shock, emotional stress; so she could not submit claim form in time and submitted final bills of hospitals to OP No.2 on 13.10.2011 for payment of balance amount, but despite her visits and requests; she neither received claimed amount nor any letter denying claim from OPs. She sent legal notice dated 29.10.2011 to OPs and OP No.1 replied to it by giving reference of OP No.2’s letter, but she (complainant) had never received said referred letter. OPs finally refused on pretext that: she had not submitted claim form within 7 days of death of her husband. In her complaint