Haryana

StateCommission

A/473/2015

ORIENTAL INSURANCE CO. - Complainant(s)

Versus

BIMLA MITTAL - Opp.Party(s)

J.P.NAHAR

29 Oct 2015

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal No  :      473 of 2015

Date of Institution:      25.05.2015

Date of Decision :       29.10.2015

 

The Oriental Insurance Company Limited, 23/23B, EMCA House, Ansari House, Dariya Ganj, New Delhi through its Senior Divisional Manager, now through its authorized signatory and Power of Attorney Holder Vikas Chaddha, Dy. Manager, The Oriental Insurance Company Limited, Regional Office, Surendra Building, SCO 109,110,111, Sector 17-D, Chandigarh.

                                      Appellant-Opposite Party No.1

Versus

1.      Mrs. Bimla Mittal w/o Sh. Puran Chand Mittal, Resident of House No.108, Sector 16-A, Faridabad.

Respondent-Complainant

2.      M/s Vipul Med Corp. Pvt. Ltd., 515, Udyog Vihar, Phase-V, Gurgaon-122016 through its Managing Director Directors/Principal Officer.

                                      Respondent-Opposite Party No.2

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Mr. B.M. Bedi, Judicial Member.

                                                                                                                  

Present:               Shri J.P. Nahar, Advocate for appellant.

                             None for respondent No.1.

                             (Service of respondent No. 2 dispensed with).

 

                                                   O R D E R

 

B.M. BEDI, JUDICIAL MEMBER

 

The Oriental Insurance Company Limited (for short ‘the Insurance Company’)-Opposite Party No.1, is in appeal against the order dated January 14^th, 2015, passed by District Consumer Disputes Redressal Forum, Faridabad, (for short ‘the District Forum’) in Consumer Complaint No.649 of 2009.

2.      Bimla Mittal-Complainant (respondent No.1) was insured with National Insurance Company Limited for the period from July 1^st, 1999 to June 30^th, 2000 vide Individual Medi-claim Insurance Policy Exhibit C-1 upto Rs.1.00 lac. She got renewed the policy continuously for subsequent years vide Insurance Policies Exhibits C-2 to C-6 upto June 30^th, 2006. In continuation of policy Exhibit C-6, the complainant was insured by The Oriental Insurance Company Limited from June 29^th, 2007 to June 28^th, 2008 vide policy Exhibit C-8 and it continued so vide policies Exhibit C-9 upto 26^th June, 2009 and then till June 27^th, 2010 vide Exhibit C-10.

3.      During the subsistence of the Insurance Policy, the complainant fell ill. She remained admitted in Deep Medical Centre Private Limited, Faridabad for different periods from February 16^th, 2007 to July 10^th, 2007. Thereafter, she remained admitted in Escorts Heart Institute & Research Centre, Okhla Road, New Delhi from February 22^nd, 2008 to February 27^th, 2008. She also took treatment from Sarvodya Hospital, Faridabad where she remained admitted from March 13^th, 2008 to March 20^th, 2008. According to the complainant she spent more than Rs.2.00 lacs on her treatment. Claim being submitted with the Insurance Company but the same was repudiated by the Insurance Company on the ground that the complainant was suffering from pre-existing disease before taking the policy and therefore she was not entitled for the benefits of insurance in view Clause 4.1 of the policy.

4.      Aggrieved of the repudiation of her claim, she filed complaint under Section 12 of the Consumer Protection Act, 1986 (for short ‘the Act’).

5.      The complaint was contested by the Opposite Parties by filing reply taking ground stated above and prayed for dismissal of the complaint.

6.      On appraisal of the pleadings of the parties and the evidence brought on the record, the District Forum accepted complaint directing the opposite parties as under:-

“9.     Opposite Parties are directed to pay Rs.1,00,000/- with interest @ 9% p.a. from the date of filing of this complaint till realization of amount within 30 (thirty) days from the date of receipt of this order to the complainant. Opposite parties are also directed to pay Rs.5500/- as compensation towards mental agony, harassment alongwith Rs.2200/- as litigation expenses to the complainant.”

7.      The appellant-Insurance Company has assailed the impugned order taking shelter of Exclusion Clause 4.1 of the policy, which reads as under:-

“4.     EXCLUSIONS

The company shall not be liable to make any payment under this policy in respect on any expenses whatsoever incurred by any insured Person in connection with or in respect of:

1. Pre-existing health condition disease or ailment/injuries: Any ailment/disease/injuries/health condition which are pre-existing (treated/untreated, declared/not declared in the proposal form), in case of any of the insured person of the family, when the cover incepts for the firsdt time, are excluded for such insured person upto 4 years of this policy being in force continuously.”

For the purpose of applying this condition, the date of inception of the policy taken from the Company, for each insured person of the family, shall be considered, provided the renewals have been continuous and without any break in period.

………”

8.      Indisputably, the complainant had been taking the insurance policy continuously since 1999 without any break. Therefore, the Insurance Company cannot take the benefit of Clause 4.1 mentioned above. The exclusion was only upto four years while the period of continuous insurance by claimant is more than ten years. Therefore, the repudiation was not justified.

9.      In view of the above, the order under appeal requires no interference. The appeal consequently fails and is hereby dismissed.

10.    The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the complainant against proper receipt and identification in accordance with rules, after the expiry of period of appeal/revision, if any.

 

Announced: 29.10.2015

(B.M. Bedi) Judicial Member

(Nawab Singh) President

 

CL