Haryana

Sonipat

CC/59/2015

IMRAN KHAN S/O MEERUDEEN - Complainant(s)

Versus

CHOLAMANDLAM MS GENERAL INSURANCE COMPANY LTD. - Opp.Party(s)

KAMAL HOODA

20 May 2016

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SONEPAT.

                                                      

 

                                    Complaint No.59 of 2015

                                    Instituted on:14.01.2015/3.3.2015.

                                    Date of order:20.05.2016

 

Imran Khan son of Meerudeen, r/o village Jatheri, tehsil and distt. Sonepat.

     …….Complainant

 

                   VERSUS

 

Cholamandlam MS Gen. Ins. Co. Ltd., Hari Niwas Towers, Second Floor, 163, Thambu Chetty Street, Parry’s Corner, Chennai-600001, Tamil Nadu HDFC ERGO Gen. Ins. Co. Ltd., Stellar IT through its Managing Director.

                                  …Respondent.

 

COMPLAINT UNDER SECTION 12 OF

THE CONSUMER PROTECTION ACT,1986

 

Argued by: Sh. Kamal Hooda, Adv. for complainant.

           Sh. Rajiv Kuhar, Adv. for respondent.

 

BEFORE-   Nagender Singh, President.

          Smt. Prabha Wati, Member.

 

 

O R D E R

 

        Complainant has filed the present complaint against the respondent alleging therein that he is having medi claim policy from the respondent vide policy no.2842/00104196/0007/000/00 valid w.e.f. 24.2.2014 to 23.2.2015.  Unfortunately the complainant has suffered gun shot injury by the policy and he got himself admitted in Param Hospital, Kundli, Sonepat and he was referred to PGIMS Rohtak and finally from PGIMS Rohtak he was shifted to Jaipur Golden Hospital where he was admitted on 15.4.2014 and was discharged on 1.5.2014 and during the treatment in Jaipur Golden Hospital, he has sent Rs.235910/- and he has also brought the medicines from outside and the complainant is still under treatment.   After discharging from the hospital, the complainant requested the respondent to make the payment of Rs.2 lacs and the complainant has sent all the requisite documents and bills of treatment to the respondent.  But the respondent has avoided to make the payment and sent a letter dated 6.6.2014 and asked the complainant to submit a post surgical x-ray, original investigation report and copy of indoor case papers which was deposited by the complainant with the respondent.    But despite this, the respondent has repudiated the claim of the complainant vide letter dated 21.7.2014 by taking the plea of hazardous activities.  The complainant has alleged the repudiation of his claim to be wrong and illegal. So, he has come to this Forum and has filed the present complaint.

2.       In reply, the respondent has submitted that the complainant has violated the terms and conditions of the policy as on perusal of the claim documents and hospital visit report, it is revealed that member had gunshot injury by police due to voluntary carrying of alcohol in his vehicle.  As the hazardous activities and their consequences are not covered under the scope of the policy, the claim is not admissible under general exclusion clause C12  and hence the claim was rightly repudiated and the complainant is not entitled for any relief and compensation and thus, prayed for the dismissal of the present complaint.

3.       We have heard the learned counsel for both the parties and have also gone through the entire relevant documents available on the case file very carefully.

4.       Ld. Counsel for the respondent has submitted that the complainant has violated the terms and conditions of the policy as on perusal of the claim documents and hospital visit report, it is revealed that member had gunshot injury by police due to voluntary carrying of alcohol in his vehicle.  As the hazardous activities and their consequences are not covered under the scope of the policy, the claim is not admissible under general exclusion clause C12  and hence the claim was rightly repudiated and the complainant is not entitled for any relief and compensation.

         On the other hand, ld. Counsel for the complainant has submitted that the respondent only to cause unnecessary harassment and mental agony has repudiated the legal and genuine claim of the complainant.

         During the course of arguments, ld. Counsel for the complainant has placed on record the copy of judgment dated 4.5.2016 passed by the learned court of Dr Sunita Grover, Addl. Sessions Judge, Sonepat in case title as State Vs. Firoj & Imran and both the above persons were acquitted by the learned court of Dr Sunita Grover.

         In the present case, the complainant has got the treatment during the validity of the insurance policy.  From the evidence led by the complainant, it is proved that the complainant has incurred huge amount on his treatment and the rejection of the claim of the complainant by the respondent amounts to a grave deficiency  in service on the part of the respondent.

         In the present case, the complainant has claimed Rs.5 lacs alongwith interest etc. under the medi claim policy.  But perusal of the document Annexure R5 shows that the sum insured was Rs.2 lacs.  Thus, the entitlement of the complainant towards the respondent comes to Rs.2 lacs only.  Accordingly, we hereby direct the respondent to make the payment of Rs.2,00,000/- (Rs.two lacs) only within a period of 60 days from the date of passing of this order, failing which, the above said amount shall fetch interest at the rate of 09% per annum from the date of passing of this order till its realization.

         With these observations, findings and directions, the present complaint stands allowed.

         Certified copies of order be provided to the parties free of costs. File be consigned to the record-room.

 

 

(Prabha Devi-Member)                  (Nagender Singh-President)

DCDRF, Sonepat.                      DCDRF Sonepat.

 

Announced 20.05.2016