DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II

Udyog Sadan, C-22 & 23, Qutub Institutional Area

(Behind Qutub Hotel), New Delhi-110016

Case No.239/2011

Shri Raj Kumar Goyal

R/o 6, Daya Lane,

Ram Kishore Road,

Civil Lines,

Delhi-110054                                                               ….Complainant

Versus

1. Reliance General Insurance Co. Ltd.

570, Naigaon, Cross Road,

Next to Royal Industrial Estate,

Wadala [W] Mumbai-400031

Through its Director

2. Medi Assist India

T.P.A. Pvt. Ltd. F-2, Kailash Plaza,

H-252, Sant Nagar, New Delhi,

Through its General Manager,

                                                                                 ….Opposite Parties

                                                Date of Institution        : 14.07.11    Date of Order                : 17.12.19

Coram:

Ms. Rekha Rani, President

Ms. Kiran Kaushal, Member

ORDER

Ms. Kiran Kaushal, Member

1. Succinctly put the Complainant availed a mediclaim policy from M/s Reliance General Insurance Co. Ltd (OP-1) for the period of two years i.e. 04.10.2008 to 03.10.2010, for an assured sum of Rs.5,00,000/- for each year. The said policy was taken for the complainant, his wife and his daughter. The requisite premium was paid to OP-1 by the complainant.
   1. The complainant states that as per the terms of the policy the insured amount of Rs.5,00,000/- is the limit for the first year. These limits lapse at the end of the first year and the fresh limit of Rs.5,00,000/- upto to the full sum insured is applicable again for the second year.
   2. It is next submitted that in September, 2009 complainant’s wife suffered from breast cancer and she was hospitalized. The total bill raised for the first year of the policy by the hospital was to the tune of Rs.7,91,219/- and as per the policy terms and conditions Rs.5,00,000/- was  reimbursed by OP.   
   3. It is next submitted that on 05.12.2009 wife of the complainant was again hospitalized and remained admitted in the hospital till 08.03.2010. The expenses incurred on the treatment this time were to the tune of Rs.4,19,330/-. The complainant sent the hospital bills and other requisite documents to OPs for reimbursement of the claim. But Medi Assist India (OP-2) declined the claim of the complainant vide letter dated 01.07.2010 wherein it is stated that

‘On Scrutiny of claim documents it is found that patient was admitted in the hospital on 20.02.2010 for the treatment of right breast carcinoma for which chemotherapy was done. This claim admissible but denied due to balance sum insured exhausted, hence as per policy definition 21 claim is denied. Hence, we regret our inability to admit this liability and claim is being repudiated under above mentioned clause and conditions’.

For ready reference Definition 21 is reproduced as under :-

Clause 21 definition : Sum insured means the sun as specified in the Schedule to this Policy which sum represents the Company’s Maximum liability for any or all claims under this Policy during the Policy period, subject to the terms and conditions of the policy.

The complainant not convinced by the reasoning for repudiating the claim, made various representations to the OPs for clearing the aforesaid mediclaim but all in vain.

1. Aggrieved, the complainant approached this Forum with the prayer to direct OPs to reimburse the mediclaim amount to the tune of Rs.4,19,330/- along with interest @ 24% per annum. It is next prayed that OPs be directed to pay Rs.10,00,000/- towards compensation and Rs.21,000/- towards the cost of litigation.

2. As none appeared on behalf of OPs despite the service of notice, OP-1 was proceeded against exparte vide order dated 16.11.2011 and the defence of OP-2 was stuck off vide order dated 19.10.2012.
3. Submissions made on behalf of the complainant are heard and material placed on record is perused carefully.
4. Averments made in the complaint and evidence led by the complainant have remained uncontroverted and unchallenged. Hence, there is no reason to disbelieve the version of the complainant.
5. Complainant in support of his case among other documents has filed Reliance Health Wise Policy Schedule. Going through the policy schedule it is noticed that the complainant is one of the insured persons of the policy in question. The tenure of the policy is two years and the sum assured is Rs.5,00,000/-. The period of insurance is from 04.10.2008 to 03.10.2010. There is a note worth mentioning on Reliance Health Wise Policy Schedule which is reproduced as under for ready reference:-

Note:- All benefits mentioned above excluding critical illness are subject to the overall sum insured applicable. In case of two year policies, the sum assured mentioned above is the limit for the first year. These limits will lapse at the end of the first year and the fresh limits up to the full Sum Insured as mentioned above will be applicable again for the Second Year.”  

6. We are of the opinion that though the claim of the complainant was reimbursed in the first year of the policy but as per the above note on the policy schedule the complainant is entitled again to receive the full sum insured for the second year. Hence for the reasons stated above, we find no reason for OP to have rejected the claim. We allow the complaint and direct OPs to reimburse /pay Rs.4,19,330/- along with interest @ 4% per annum from the date of filing of the complaint till realization.
7. OPs are directed to pay the complainant within a period of 60 days from the date of receipt of the copy of this order failing which the OP shall become liable to pay interest @ 6% per annum on Rs.4,19,330/- from the date of filing of the complaint till realization.

          Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations.  Thereafter file be consigned to record room.

Announced on 17.12.19