BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

AT SOUTH MUMBAI- PAREL

Mr. Y
405/ Vatsalya Co-op. Society,
Hindu Colony, Dadar (East),
Mumbai-400014
Versus
Reliance Insurance Company Ltd.
Gautam Nagar, Dadar,
Mumbai-400014

COMPLAINT UNDER SECTION 12 OF THE CONSUMER PROTECTION ACT 1986

May it please Your Honor:

1. Mr. Y (hereafter referred to as Complainant) is an I.T. professional working in

the I.T. firm called Accenture for the past 25 years of employment.

2. Reliance Insurance Company Ltd. (hereafter referred to as the Opposite

Party) is the licensed insurance company engaged in the business of

insurances in India.

3. The Complainant submits that he is a consumer within the definition of

section 2(1)(d) of Consumer Protection Act 1986 (hereafter referred to as the

said act) and is constrained to approach this Hon’ble Forum against the gross

acts of the opposite party who are guilty of committing deficiency of services

and unfair trade practices within the definition and meaning of section 2(1)

(g)&(h) of the Said Act.

health insurance package bearing no.:1234567890 (hereafter referred to as

said policy) from the Opposite Party. The said policy provides the immunity

to the extent of Rs. 2,000,000(Twenty Lacs rupees) in case of hospitalisation

for the treatment of an ailment. (Copy of the said policy annexed and marked

as Annexure-1).

5. The Complainant states that an annual premium of Rs. 54,954/- (Fifty Four

Thousand Nine Hundred and Fifty Four rupees only) was paid to the opposite

party on time. (Copy of all the cheques paid to the opposite party marked

and annexed as Annexure-2)

6. The Complainant further submits that on 10th August 2018 at about 12 pm he

suffered from perspiration and loss of consciousness and was rushed to the

nearby hospital namely “Mahalaxmi Hospital” (hereafter referred to as said

hospital)

7. On arriving the hospital, Dr. Singhania (Cardiologist) made Complainant

undergo various tests such as Electrocardiogram, Cardiac computerized

tomography (CT) scan and Cardiac magnetic resonance imaging (MRI). The

report of Cardiac computerized tomography (CT) scan indicated the build-up

of calcium in the coronary arteries and pericardial disease (Copy of these

test reports marked and annexed as Annexure-3). The doctors found it

urgent to operate him on the basis of the above reports.

8. On 10th August 2018 at about 3 pm, Complainant was taken to the operating

theatre. On 11th August 2018 midnight, after a successful operation which

(ICU) for special care and treatment due to his critical condition.

9. On 11th August 2018 at about 2pm, Dr. Singhania visited the Complainant for

check-up and advised the Complainant to remain admitted in Intensive Care

Unit for a period of 1 week. On 18th August 2018, after consulting Dr.

Singhania, Complainant was sifted to the normal ward for a period of 12

days. The Complainant was given discharged on 30 th August 2018. The said

Treatment lasted for 20 days (the copy of Discharge Card is herby marked

and annexed as Annexure-4)

10.The Complainant submits that he suffered various expenses for his treatment

at the said hospital comprising of expenses on medicines, Doctor’s fees,

surgery expenses and other hospital charges. The total of all these expenses

is Rs 1,500,000(Fifteen Lacs Rupees only) (the copy of said bills is hereby

annexed and marked as Annexure-5).

11.By the letter dated 30th August 2018 to opposite party, the Complainant

requested the opposite party to initiate his rightful claim against his said

policy and therefore annexed the copies all the documents including the

reports and said bills to the said insurance company for verification. (copy of

the letter hereby marked and annexed as Annexure-6)

12.Letter (no:123344) dated 31st August 2018, the said insurance company

rejected to pay off said bills on the false grounds that the Complainant had

not provided information about the past suffering from heart ailments to the
 said insurance company. (copy of the letter hereby annexed and marked as

Annexure-7)

13.The Complainant states that, all the relevant documents pertaining to the

medical history of the Complainant i.e. blood sugar reports, his blood

pressure reports and reports pertaining to full body check-up were submitted

to the opposite party at the time issue of insurance policy which were

verified and confirmed by the opposite party. The said reports show no sign

of any ailment. (Copy of said reports hereby marked and annexed as

Annexure-8)

14.Complainant states that the officer of the opposite party was sufficiently

given all the relevant documents and was free to independently verify the

Complainant’s medical history. He further submits that he fully co-operated

with the opposite party before signing of the said policy.

15.Complainant submits that because of rejected claim on false grounds by the

said insurance company, Complainant faced great difficulty for paying of all

the said bills entirely. He further submits that he had to sell all his shares and

use his entire savings for discharging all the said bills.

16.Complainant submits that in accordance with the said rejection letter he

personally visited the office of the said insurance company to clarify any

misunderstandings caused between the parties. He further states that on

reaching the said insurance company’s office, he met the concerned officer,

who treated him inadequately. Complainant therefore could not get any of

his answers and was forced to write a letter to the head office.
17.By the letter dated 10th September 2018 to the Head of Directors of the said

insurance company, Complainant complained about the said officer and

addressed them about the said problem. (copy of said letter hereby annexed

and marked as Annexure-9)

18.Complainant states that he waited for about a month for the response but he

did not receive any response from the opposite party. Complainant further

states that he undertook several trips to the head office of the said insurance

company for clarification about the said problem and requested the meeting

with the head of the said insurance company.

19.Complainant states that in spite of several visits and letters the opposite

party did not give an affirmative reply in connection with the said policy.

20.The Complainant submits that the Opposite party is guilty of deficiency of

services and unfair trade practices due to illegally and arbitrary rejection of

Complainants claim.

21.Complainant submits that he is a bonafide consumer as defined under

section 2(1)(d) of the Consumer Protection Act 1986 as he has availed

services towards insurance as defined under section 2(o) of the said act. The

Complainant further submits that he has paid consideration in form of

insurance premium and thus undoubtedly a consumer qua the opposite

party.
22.Complainant is thus entitled to receive the entire claim of Rs.1500000/- from

the opposite party with interest @ 9 % or any higher rate towards the loss

suffered by the Complainant, as per the statement of claim.

23.The Complainant states that considering the above facts and circumstances

of the complaint, it is prima facie proved that the opposite party has acted in

unlawful, illegal and in the most unfair manner and thus it is beyond any

reasonable doubt that the opposite party is guilty of committing deficiency of

services and unfair trade practices within the definition and meaning of the

Said Act.

24.The Complainant resides and carry on business in Mumbai. The Opposite

party has its registered office and its branch and processing office in

Mumbai. However, since the amount claimed is below Rs.20,00,000 (Twenty

Lacs Rupees), only this Hon’ble Forum has the jurisdiction to try, entertain

and decide this consumer complaint.

25.The Complainant submit that the cause of action arose on 31 st August 2017,

when the Opposite Party had rejected the claim of the Complainant. The

present complaint is therefore within the period of limitation; as prescribed

under section 24-A of the said act.

26.The Complainant hereby submits that he has not filed any complaint before

any other Court/Forum or Authority in respect of the above Insurance Policy

against the Opposite Party.

foregoing paragraphs; if and when found necessary, with the permission of

this Hon’ble Forum.

28.The Complainants crave leave to refer to and rely upon the documents

annexed hereto and further crave leave to file additional document/s in

support of their contentions, if required with the permission of this Hon’ble

Forum.

29.The Complainants therefore in the view of the submissions contained in the

preceding paragraphs, most respectfully prays to the Hon’ble Forum to direct

the opposite party to:

a. to allow the complaint, to hold and declare that the Opposite Party is

guilty of deficiency in service and unfair trade practices; as per

provisions of the Consumer Protection Act,1986:

b. to direct opposite party to pay to the Complainant a sum of

Rs15,00,000/- along with interest @ 9% from 31/08/2017 till

realization:

c. to direct opposite party to pay to Complainant an amount of

Rs.1,00,000/- towards compensation for mental agony and physical

strain suffered by the Complainant

d. to pay a sum of Rs. 25,000/- towards the cost of this petition

the case may deem fit and proper.

For which act of kindness, the Complainant shall, as is

duty bound, ever pray.

COMPLAINANT

Advocate

VERIFICATION

I, Mr.
of the Complainants abovenamed do hereby state and verify that
whatever has been stated in the foregoing paragraphs of the
complaint are true and correct to the best of my knowledge and belief
and I believe the same to be true.

COMPLAINANT
 BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM
AT SOUTH MUMBAI- PAREL
CONSUMER COMPLAINT NO.: OF 2018

Mr. Y
405/ Vatsalya Co-op. Society,
Hindu Colony, Dadar (East),
Mumbai-400014
Versus
Reliance Insurance Company Ltd.
Gautam Nagar, Dadar,
Mumbai-400014
AFFIDAVIT IN SUPPORT OF THE COMPLAINT

I aged years
presently at Mumbai, do hereby solemnly affirm and declare as under: -
1. I say that I am fully conversant with the facts of the present
complaint and I am therefore able to depose to the same. I have filed
the above complaint, seeking prayers more particularly mentioned in
the complaint.

2.I, for the sake of brevity, repeat and reiterate each and every
statement, submissions and contentions made in the complaint as if
the same are specifically set out herein and form part and parcel of
this affidavit. I affirm and verify the correctness of the each and
every statement, submissions and contentions as set out in the
complaint.

3.I say that if the reliefs as prayed for in the complaint are not
granted, would cause great harm, loss and prejudice to the
Complainant. In the circumstances, the reliefs as prayed for in the
complaint be granted and the complaint be made absolute with
costs.

4.I say that the present affidavit is being filed bona fide and in the
interest of justice.

Complainant