IN THE STATE COMMISSION: DELHI

(Constituted under Section 9 of the Consumer Protection Act, 1986)

                                                             Date of Decision: 29.03.2019

First Appeal No. 387/2013

(Arising out of the order dated 01.02.2013 passed in complaint case No. 1819/2008 by the District Consumer Disputes Redressal Forum-VI, Vikas Bhawan, I.P. Estate, New Delhi-110001.)

In the matter of:

New India Assurance Co. Ltd

Through its Delhi Regional Office-II

1/12 IInd Floor,

Jeevan Raksha Building,

Asaf Ali Road

New Delhi-110002                                                         ….......Appellant

Versus

1.  Jagjit Singh

S/o Late Shri Inder Singh

R/o A-502, Kaveri Apartments

New Delhi-110019                                                         .......Respondent

           2.  TTK Healthcare TPA Pvt. Ltd.

              (Through its Managing Director/Regional Manager)

              103/104, First Floor, Rohit House #3,

              Tolsto Marg, Cannaught Place,

              New Delhi                                                          .....Performa 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?                                                                                                     

SALMA NOOR            -           MEMBER

1.  Present appeal is filed under Section 15 of the Consumer Protection Act 1986, (in short the ‘Act’) wherein challenge is made to order dated 01.02.2013 in CC No.1819/08 passed by the Consumer Disputes Redressal Forum-VI, Vikas Bhawan, New Delhi (in short the ‘District Forum)’.
2.   Brief facts of the case are that the respondent/complainant and his wife had been taking policy from appellant/OP by the name of “Good Health Policy Certificate” for the last 08 years and had renewed the policy for the period of 01.09.2007 to 31.08.2008 for a sum insured of Rs.1.5 lakhs. On 26.10.2007, respondent/complainant was hit by a fast moving car which resulted in right knee injury. He was immediately taken to Max Super Specialty Hospital where doctor diagnosed loosening of the implant of total knee replacement done 12 years back and recommended operation to reduce the pain. It was stated that respondent/complainant had total knee replacement of bilateral knee joint on 17.10.1996 for osteo-arthritis. It was further stated that as per the doctor’s certificate dated 07.05.2008, loosening of the implant was due to being hit by a car. The respondent/complainant was admitted to Max Super Specialty Hospital for said operation on 06.07.2008 and underwent right leg knee joint operation. The respondent/complainant stated that he had applied for cashless request of treatment which was declined by appellant/OP. Respondent/complainant was discharged on 10.07.2008. On 27.08.2008 respondent/complainant submitted his claim for reimbursement of medical expenses and claimed total amount of Rs.3,05,833/-. It was further stated that vide letter dated 01.10.2008 appellant/OP-1 rejected the claim of respondent/complainant on the ground that in accordance with the clause 4.1 of the policy, the expenses incurred for an already existing ailment and its complication were not payable and hence the claim was repudiated.
3. Aggrieved by the repudiation of the claim, respondent/complainant had filed a consumer complaint before the Ld. District Forum with the following prayers:-

1. Pass an orders against OPs and may kindly be directed to pay jointly and severally on account of Medi-claim compensation sum of Rs.3,05,833/-.
2. Pass an orders against OPs and may kindly be directed to pay jointly and severally on account of deficiency of service sum of Rs.50,000/- on account mental and physical agony.
3. Pass an orders against OPs a