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007-B, Shiv Shakti Apts.,
Veer Savarkar Road,
Dombivli 421 201. Appellant(s)

M/s.New India Insurance
Co. Ltd.,
D.O.17-A, News India Centre,
8th floor, Cooperage Road,
Mumbai 400 039. Respondent(s)

Hon’ble Mr.Justice A.P.Bhangale, President
Hon’ble Dr.S.K.Kakade, Member

For the
Appellant(s): Advocate Shri. V.K.Karve
For the
Respondent(s): Advocate Shri.Bhalerao

Per: Hon’ble Mr.Justice A.P.Bhangale, President

[1] This appeal is filed by the complainant who was aggrieved by

impugned Award which according to complainant is a meager Award and
therefore he has appealed against it to call us to award compensation which
is just and reasonable in the facts and circumstances of the case.

[2] It appears that the learned District Consumer Disputes Redressal

Forum Thane in consumer complaint No.CC/14/534 decided on 06/01/2016
was pleased to limit the Award to the sum of Rs.5,500/- towards M.R.I.
charges and consultation charges in the sum of Rs.1060/- apart from
compensation for mental harassment in the sum of Rs.15,000/- and
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litigation costs in the sum of Rs.5,000/- within 45 days from the date of

[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.

[4] Appellant/complainant also prayed for compensation on account of

mental and physical harassment as also litigation costs.

[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.
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[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

[8] According to the learned Advocate for respondent in the Prospectus

as to Union Health Care Policy issued jointly with Union Bank of India by
The New India Assurance Co. Ltd., ‘Pre-Hospitalisation’ means -relevant
medical expenses incurred during period upto 30 days prior to
hospitalization on disease/illness/injury, sustained will be considered as part
of claim mentioned under item 1.2 thereof. It is not known as to whether
this prospectus was read-over and interpreted to the complainant when
policy contract was entered into even assuming for the sake of argument
when the claim was lodged in the sum of Rs.58,678/- much below of
assured amount which ought to have been considered on the basis of
documents tendered by the complainant as according to the complainant on
18/04/2012 son of complainant was admitted in the hospital and on
13/03/2012 he had consulted Dr.Joshi for surgery. M.R.I.test was necessary
before surgery. Under these circumstances, insurer could not have refused to
pay incidental and consequential expenses merely on the ground that
surgery or M.R.I. were not within 30 days prior to actual hospitalization. In
our view, consultation and pre-surgery test expenses cannot be refused
merely on the ground that the complainant had spent the amount 30 days
prior to the actual surgical operation. In the facts and circumstances of the
case when mediclaim was to the assured sum of Rs.1,00,000/- and the claim
made by the complainant was in the sum of Rs.58,678/-, much below the
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coverage amount and was supported by the documents, it ought to have

been allowed by the Insurance Company as the amount included fees of
surgery as well as consultation charges, M.R.I. charges, gloves etc. Under
these circumstances, appeal is partly allowed and impugned Award is
modified in following terms-


1] Appeal is hereby partly allowed.

2] Complaint bearing No.534 of 2014 is partly allowed as


[i] Complainant is entitled to receive sum of Rs.58,678/-

(Rupees Fifty Eight Thousand Six Hundred and Seventy
Eight only) from opponent/Insurance Company.

[ii] We also allow and maintain compensation amount in

the sum of Rs.15,000/- (Rupees Fifteen Thousand only)
and litigation costs in the sum of Rs.5,000/- (Rupees
Five Thousand only) awarded in favour of complainant.

[iii] We further award costs of this appeal in the sum of

Rs.10,000/- (Rupees Ten Thousand only) payable in
addition to the complainant/appellant by the respondent.

[iv] Awarded amount shall be paid within 30 days from

the date of receipt of copy of this order. Amount
deposited, if any, shall be allowed to be withdrawn by
the appellant/ complainant and shall be appropriated
accordingly towards the dues pursuant to this order.
Amount remain unpaid within 30 days shall carry
interest @9% p.a. from the date amount became payable
till realization.
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Certified copy of this order be supplied to both the parties.

Pronounced on
17th December, 2018.