BEFORE THE DISTRICT CONSUMER FORUM, NEW DELHI

COMPLAINT NO. OF 2014

IN THE MATTER OF

Shri Anil Tiwari

R/o 4014, Raghu Ganj,
Chawri Bazaar
Delhi – 110006

Madhu Tiwari
w/o Mr. Anil Tiwari
4014, Raghu Ganj,
Chawri Bazar, Delhi – 110 006. Complainants

Versus

1. Oriental Insurance Company Limited

Through its Chairman/ Manager,
C/o A-25/27,
Asaf Ali Road.
New Delhi – 110002

2. M/S Saket City Hospital

Through its Incharge
Mandir Marg, Press Enclave Road
Saket, New Delhi-110017 Opposite Party

COMPLAINT UNDER SECTION 12 OF THE CONSUMER PROTECTION ACT

AGAINST THE NATIONAL INSURANCE COMPANY LTD FOR GRANT OF
COMPENSATION AND CLAIM AMOUNT.

MOST RESPECTFULLY SHOWETH :

1. That the complainant is a consumer as per the definition of a consumer as given in a

consumer protection act being a policy holder of Mediclaim Policy vide policy no.
272900/48/2014/18002 for the period of 28-03-2014 to 27-03-2015 (midnight) issued by
the opposite party in favour of the complainant for sum insured amounting to Rs
5,00,000/-. Photocopy of the insurance is enclosed herewith as Annexure – A.

2. That it is respectfully submitted that the complainant is a regular customer of opposite

party since 2012 to till date and it is not out of place to mention here that there is not
even a single day break in the said policy and the complainant used to pay the premium
very diligently. This fact can be verified from Annexure -A also.

3. That the complainant’s wife suddenly faced some problem in her body. Hence she
visited respondent no.2 Hospital and consulted with the doctor on 14/04/2014 and
accordingly doctor prescribed him to get admitted for surgery of Leiomyoma of Uterus
After consultation the complainant’s wife got admitted in the respondent no.2 hospital. It
is pertinent to mention here that the complainant was forced to deposit Rs 10,000/- as
security and given an assurance that the same will be refunded back at the time of
discharge of the patient.
4. That the respondent no.2 had forwarded the claim of the complainant for the approval of
respondent no.1 through their TPA i.e. M/S Medi Assist TPA Pvt. Ltd for her cashless
mediclaim and the said approval was given by the said TPA i.e. M/S Medi Assist TPA
Pvt. Ltd under the policy for an amount of Rs 38,000/- Pre Authorization no.
9944941and thereafter the complainant and his wife got the assurance from the
respondent no.1 that nothing will be payable thereafter as it was the package, which
includes everything,

5. That the complainant’s wife was gone under the surgery on 16/04/2014 and nothing
neither was informed nor was the permission ever taken by the respondent no.2 about
the second operation neither to the TPA i.e. M /S Medi Assist TPA Pvt. Ltd nor to the
complainant.

6. That after the operation the complainant’s wife was shifted to the room no.1207 and at
that time also nothing was informed to the complainant.

7. That the respondent no.2 committed a breach of trust as they have charged twice for
the similar things as mentioned in their own Bills details That the amount of Rs 38,000/-
was already charged by the respondent no.2 for open/Lap Hysterectomy
(Abdominal/Vaginal) in which the charges of Operation Theatre as well as of the
General Anesthesia was already included and the same was already paid by the
respondent no.1. Copy of the various reports including discharge summary prepared by
respondent no.2 is enclosed herewith as Annexure B (colly).

8. That the respondent no.1 assured the complainant about the package and its inclusion
and they further assured the complainant or his wife that nothing is payable to the
hospital as they are using cashless insurance of Rs 5,00,000/-.

9. That in view of the above it is stated that the respondent no.2 have harassed the old
aged couple, as they made the bill at about 5.37 pm and informed about the same at
about 7.30 pm to the complainant, when the office of the respondent no.1 was closed.

10. That not only this, the respondent no.2 restrained the complainant and his wife to leave
hospital without paying their full charges to the tune of Rs 55,003/-. Copy of the invoice
is enclosed herewith as Annexure C.

11. That finding no other option, the complainant was forced to pay Rs 7,003/- exclusion of
Rs 38,000/- (paid by respondent no.1’s TPA i.e. M/S Medi Assist TPA Pvt Ltd.) and also
in exclusion of Rs 10,000/- being paid by the complainant as security/advance at the
time of admission) for the discharge of his wife under pressure.

12. That thereafter the complainant and his wife visited several times and tried to contact
both the respondents for his hard earned money, which they duped from him and further
 spend their time and money on the same, but nothing was happen. Hence they cheated
the complainant and grabbed her hard earned money.

13. That it is very surprising that till date neither the TPA of the opposite party nor the
opposite party no.2 either repudiate the balance genuine claim of the complainant or
settled the claim.

14. The complainant was shocked to see the conduct and behaviour of the opposite party
and again approached the opposite party to consider his claim vide legal notice dated
28th July 2014 but the respondents did not pay any heed or attention to either settle the
claim rather they replied the said letter on false and flimsy grounds. Copy of legal notice
dated 28th July 2014 and the reply is annexed herewith as Annexure D & E.

15. That thereafter about Two months were passed but the complainant did not receive any
intimation about the process of claim.

16. That it is respectfully submitted that the complainant is a very loyal customer of the
opposite parties for many years still he was unnecessarily harassed and no proper reply
was given to his letters/requests. By not attending the claim by the officials of the
insurance company, the owner of the policy holder gets unnecessary trouble and
mentally torturing.

17. That the cause of action against the opposite party arose on various dates from 14 th
April 2014 to 16th April 2014, when the complainant was admitted in the hospital due to
ill health, then cause of action against the opposite party arose on various dates when
the complainant was unnecessarily harassed for not replying or settling the claim even
after passing of almost one year.

18. That the cause of action has arisen within the territorial jurisdiction of the Hon’ble
District Forum.

19. That there has been no delay in filing the present complaint.

20. That no other similar complaint has either been filed before any other district forum or
the same is pending before any District Forum.

21. That there is no relief, which does not fall within the purview or power of this forum is
being claiming by the complainant through the complaint.

PRAYER

It is therefore most respectfully prayed that in view of the above facts and
circumstances mentioned above this Hon’ble Forum may kindly be pleased to :-
a. Pass an order against the insurance company to pay an amount of Rs. 55,003/- (Rs
Fifty Five thousand three only) being the claim amount to the complainant.
b. Allow interest at the rate of 18% per annum from April 2014 till the date of submission of
the present complaint and pass an order in favour of the complainant and against the
Opposite Parties with a direction to the Opposite Parties to pay the complainant said
interest.

c. Allow damages for causing harassment, business loss due to negligence of the
opposite parties to the extent of Rs. 50,000/- (Rs. Fifty Thousand Only) and Pass an
order in favour of the complainant and against the Opposite Parties for deficiency of
service as well as for adopting unfair trade practice.

d. Allow the Cost of Litigation and pass an order in favour of the complainant and against
the Opposite Parties with a direction to the Opposite Parties to pay the litigation cost.

e. Allow pendalite interest at the rate of 18% per annum from the date of submitting the
present complaint till the date of payment and pass an order in favour of the
complainant and against the Opposite Parties in this regard.

f. Pass such further order/orders as this Hon’ble Forum may deem fit and proper in the
facts and circumstances of the case and in the interest of the justice.
Filed by :

COMPLAINANT
THROUGH

COUNSEL
PLACE : NEW DELHI
DATE : 21-12-2014

VERIFICATION
Verified at Delhi on this the …….. day of April 2014 that the contents of Para No. 1 to 10
of the complaint are true and correct to the best of my knowledge and those of para 11 to 13 of
the complaint are based on legal advice, which I verify believing to be true. Last Para is prayer
clause to this Hon’ble Court.

COMPLAINANT
 BEFORE THE DISTRICT CONSUMER FORUM, NEW DELHI

COMPLAINT NO. OF 2014

IN THE MATTER OF

Shri Anil Tiwari

R/o 4014, Raghu Ganj,
Chawri Bazaar
Delhi – 110006 Complainant

Versus

1. Oriental Insurance Company Limited

Through its Chairman/ Manager,
C/o A-25/27,
Asaf Ali Road.
New Delhi – 110002

2. M/S Saket City Hospital

Through its Incharge
Mandir Marg, Press Enclave Road
Saket, New Delhi-110017 Opposite Party

AFFIDAVIT

I, Anil Tiwari S/o Shri M. P. Tewari, R/o 4014, Raghu Ganj, Chawri Bazaar New Delhi –
110006, do hereby solemnly affirm and declare as under:

1. That the above named deponent is the complainant and thus she is fully conversant
with the facts and circumstances of the case and she is competent enough to swear this
affidavit.

2. That the accompanying Complaint under Section 11 of consumer Protection Act has
been drafted by my counsel under my instructions and the contents of the same are true
and correct.

DEPONENT
VERIFICATION
Verified at New Delhi on this …… of December, 2014 that the contents of para 1 to 2 of
the above affidavit are true to the best of my knowledge and belief and nothing material
has been concealed therefrom.

DEPONENT