Professional Documents
Culture Documents
Medical Insurance
Medical Insurance
Medical Insurance
Shri.V.Sridhar
007-B, Shiv Shakti Apts.,
Veer Savarkar Road,
Dombivli 421 201. Appellant(s)
versus
M/s.New India Insurance
Co. Ltd.,
D.O.17-A, News India Centre,
8th floor, Cooperage Road,
Mumbai 400 039. Respondent(s)
BEFORE:
Hon’ble Mr.Justice A.P.Bhangale, President
Hon’ble Dr.S.K.Kakade, Member
PRESENT:
For the
Appellant(s): Advocate Shri. V.K.Karve
For the
Respondent(s): Advocate Shri.Bhalerao
ORAL ORDER
Per: Hon’ble Mr.Justice A.P.Bhangale, President
litigation costs in the sum of Rs.5,000/- within 45 days from the date of
order.
[3] We have heard submissions at the bar. It does appear that the
complainant had taken Mediclaim policy bearing No.
13120034110400000001. Policy covers complainant as well as his son and
wife during the validity period of 02/01/2012 to 01/01/2013 for the sum of
Rs.1,00,000/-. It is the case of complainant that, his son during the validity
period underwent surgery of his knee joint for which complainant lodged
claim of Rs.58,678/-. However, respondent/opponent refused to honor the
claim except to the extent of Rs.17,852/-. Later when inquiries were made,
claim in the sum of Rs.30,856/- was approved by the opponent but it refused
to award compensation for expenses prior to hospitalization and non-
medical expenses. Complainant had spent his time, money and energy to
follow it up with the insurer for awarding just and proper compensation
which according to the complainant was to the tune of Rs.2,11,560/- plus
interest payable @12% p.a.
[5] We also find that the complainant had already approached the
Insurance Ombudsman for Maharashtra and Goa with complaint No.GI
1941 (2012-13) with appeal No.855 of 2013-14. Ombudsman was pleased
to direct payment of Rs.2,910/- with interest @10.5% p.a. on all the
settlement amounts from 11/06/2012 upto the settlement dates of the
respective claim amounts, in respect of hospitalization of his son in
Shushrusha Citizens’ Co.Op.Hospital Ltd. for ACL Reconstruction from
18/04/2012 to 21/04/2012 which according to the complainant was very
meager amount.
3 (A/16/167)
[6] We find that mediclaim policy taken by the complainant was for the
sum of Rs.1,00,000/- as assured amount. But the claim which was lodged by
the complainant for the medical treatment of his son was in the sum of
Rs.58,678/- only with the Insurance Company.
[7] It also appears from the Judgment and Award by the learned District
Forum below that the Insurance Company had failed to file their written
version and the complaint proceeded without written version against
opponent.
ORDER
[JUSTICE A.P.BHANGALE]
PRESIDENT
[Dr.S.K.KAKADE]
MEMBER
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