Haryana

StateCommission

A/60/2016

ORIENTAL INSURANCE CO. - Complainant(s)

Versus

JITENDER VATS - Opp.Party(s)

D.C.KUMAR

11 Aug 2016

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                            

                    

First Appeal No    :   60 of 2016

Date of Institution :   20.01.2016

Date of Decision   :   11.08.2016

 

 

The Oriental Insurance Company Limited, Head Office A-25/27, Asaf Ali Road, New Delhi through Sh. S.P. Singh, Regional Manager, The Oriental Insurance Company Limited, Regional Office, LIC Building, 2^nd Floor, Jagadhari Road, Ambala Cantt.

                   Appellant-Opposite Party

Versus

 

Jitender Vats son of Sh. Bal Kishan Sharma, resident of House No.46A, Raj Mohalla, Near Old Sabzi Mandi, Sonepat.

Respondent-Complainant

 

                            

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

                             Shri B.M. Bedi, Judicial Member

                             Shri Diwan Singh Chauhan, Member                                                                                                                                         

Present:              Shri D.C. Kumar, Advocate for appellant

                             Shri R.S. Saroha, Advocate for respondent

 

                                                   O R D E R

 

B.M. BEDI, JUDICIAL MEMBER

 

The Oriental Insurance Company Limited-opposite party (for short ‘Insurance Company’) is in appeal against the order dated 18.11. 2015 passed by District Consumer Disputes Redressal Forum, Sonepat (for short, ‘District Forum’) whereby complaint filed by Jitender Vats-complainant was allowed.  Operative part of the order is reproduced as under:-

“………..Accordingly, it is held that the action taken by the respondent in the matter of the complainant is wrong, illegal and unjustified and thus, it is directed to the respondent to make the payment of Rs.2,04,238/-to the complainant within a period of 45 days from the date of passing of this order, failing which, the above said amount shall fetch interest at the rate of 9% per annum from the date of passing of this order till its realization…”

2.      Complainant obtained Mediclaim Policy on 23.03.2007 initially for the period of one year and thereafter it was renewed every year upto 22.03.2012.  Initially the cover was upto Rs.1.00 lac.  However on 23.03.2012, the complainant at the time of renewal got it converted into a Happy Family Floater Policy and enhanced the risk upto Rs.3.00 lac.  On 31.05.2012, complainant suffered severe pain in his hand and received treatment from Metro Hospital, Faridabad. Thereafter, at GB Pant Hospital, Delhi where angioplasty was done and four stents were inserted.  Complainant spent Rs.2,77,158/- and Rs.18,780/- respectively on his treatment.  The Insurance Company paid only Rs.91,690/-.  The complainant filed complaint before the District Forum.

3.      The Insurance Company contested the complaint by filing reply.  The Insurance Company admitted that complainant obtained mediclaim policy commencing from 23.03.2007 and thereafter it was renewed.  It was also admitted that initially insurance cover was upto Rs.1.00 lac.  It was also admitted that the complainant got converted the policy into Happy Family Floater Policy with enhanced risk cover upto Rs.3.00 lac with effect from 23.3.2012 upto 23.03.2013.  The plea was raised that in view of clause 4.1 of the terms and conditions of the policy, the limit of Rs.1.00 lac was to continue for four years.  It was prayed for dismissal. 

4.      Learned counsel for the Insurance Company referred clause 4.1 of the terms and conditions of the policy, which is reproduced below:-

                   “4.1   Pre-existing health condition or 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 first time, are excluded for such insured person upto 4 years of this policy being in force continuously.”

 

5.      Admittedly, it is not a fresh mediclaim policy.  The policy commenced from 23.03.2007.  It is also not in dispute that the policy was renewed continuously without any break.  Clause 4.1 only deals with pre-existing disease with exclusion period upto 4 years.  The policy has commenced from March 2007 while complainant received treatment in March, 2012.  The period of four years has already crossed.  Besides this, it was not a case of pre-existing disease.  Therefore, clause 4.1 was not attracted.  If Insurance Company was to cover risk upto Rs.1.00 lac for four years, there is no point in enhancing the risk upto Rs.3 lac.  Morever, the shelter of clause 4.1 being sought only pertains to pre-existing disease and does not contain any bar of covering the enhanced risk.  In view of this, there is no illegality or irregularity discernible in the impugned order passed by the District Forum.  Thus, the appeal is dismissed.    

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

 

Announced 11.08.2016

(Diwan Singh Chauhan) Member

(B.M. Bedi) Judicial Member

(Nawab Singh) President

UK