Page 26 - Suri’s - NCDRC ON LIFE INSURANCE 2017 V1.3

Suri’s - NCDRC ON LIFE INSURANCE 2017 26

FORE:
HON'BLE MR. JUSTICE AJIT BHARIHOKE,PRESIDING
MEMBER
HON'BLE MR. ANUP K THAKUR,MEMBER

For the Peti-
tioner : Ms. Meenakshi Midha, Advocate

For the Respon-
dent : For the Respondent No.1 : NEMO

For the Respondent No.2 : Ex-Parte

Dated : 24 Oct 2017
ORDER
This revision is directed against the order of the Haryana State Consumer Disputes
Redressal Commission, Panchkula (in short, ―the State Commission‖) dated
21.9.2016 in first appeal No.192/2016 whereby the State Commission concurred with
the order of the District Forum, Sirsa and dismissed the appeal.
2. Briefly stated, facts relevant for the disposal of the revision petition are that
the complainant/respondent No.1 purchased a medi-claim insurance policy from the
petitioner/insurance company on payment of premium. The policy promised cashless
treatment in the event of any ailment subject to the terms & conditions. The policy
th
th
was effective w.e.f. 28 March, 2012 till 28 March, 2015. M.D. India Healthcare
Services (TPA) Pvt. Ltd. was third party service provider under the aforesaid policy.
3. On 11.4.2013 the complainant developed pain in his chest. He approached
Dr. Ajai Poonia who after preliminary examination referred the complainant to
AIIMS for further management. The complainant, however, approached Medanta The
Medicity, Gurgaon under intimation to opposite party No.3. Medanta hospital being a
costly institute, the complainant went to Sri Balaji Action Medical Institute, Paschim
Vihar, New Delhi where he remained from 21.4.2013 to 29.4.2013. The complainant
incurred expense of Rs.1,75,280/- in Sri Balaji Action Medical Institute and
Rs.36,716/- in Medanta hospital. It is the case of the complainant that he lodged his
claim for cashless treatment with the petitioner insurance company which was for-
warded to respondent No.3 TPA for settlement. The respondents, however, denied
cashless treatment on the premise that there was a possibility of the complainant hav-
ing concealed information about his previous ailments. It is further the case of the
complainant that thereafter he approached the petitioner/respondent for settlement of
his claim but the petitioner continued to put off the matter on one pretext or the other.
The complainant, thus, served the petitioner with a legal notice dated 19.6.2013. De-
spite that the petitioner refused to settle the claim. Feeling aggrieved, the complainant
raised a consumer dispute by approaching the District Forum, Sirsa.
4. The petitioner/opposite party resisted the complaint by filing written state-
ment. According to the petitioner insurance company, it only rejected the request of
the respondent/complainant for cashless treatment because there was a possibility of

INDEX