Delhi

New Delhi

CC/346/2011

Ishwer Persad Goel - Complainant(s)

Versus

M/S The Oriental Insurance Company Ltd. - Opp.Party(s)

29 Mar 2022

ORDER

 

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-VI,

DISTT.NEW DELHI M-BLOCK, VIKAS BHAWAN, I.P. ESTATE, NEW DELHI-110002

 

                                                                                            CC. NO.346/2011

 

In the matter of:

ISHWAR PRASAD GOEL

RZ1-12B,OLD SOM BAZAR WALI GALI,

POOJA DIGITAL STUDIO,

PALAM DABRI ROAD,

DELHI-110045                                             ……..Complainant

VERSUS

1. THE ORIENTAL INSURENCE CO. LTD.

          BOMBAY LIFE BUILDING,

         N-36, CONNAUGHT CIRCUS,

         NEW DELHI-110001

2. THE RAKSHA T.P.A. PVT. LTD.

          15/5, MATHURA ROAD, FARIDABAD,

            HARYANA-121003.                    ………Opposite Party(ies)

 

CORAM : SH. POONAM CHAUDHRY, PRESIDENT

                SH. BARIQ AHMAD, MEMBER

      MS. ADARSH NAIN, MEMBER   

                                                 Date of Institution: 25.03.2011

                                                          Date of Order      : 29.03.2022

BARIQ AHMAD, MEMBER

ORDER

Hearing Through Video Conferencing.

1. The complainant has filed the present complaint against the OPs under section 12 of Consumer Protection Act, 1986. The gist of the complaint is that the complainant, his wife Smt. Shashi Devi  were mediclaim policy holder of the OP Co., through policy No.215100/48/2010/3470 valid from 17.02.2010 to 16.02.2011. The complainant filed the present complaint being aggrieved by the rejection of his claim by OP Insurance Co. vide their letter dated 09.02.2011 on the ground of claim file closed/no claim. He further stated that on 01.09.2010 send an intimation letter to OP about the hospitalization to Ekansh Nursing Home for the treatment of fever with Thrombocytopenia and discharged on 06.09.2010, thereafter submitted a claim of Rs.52,687/- along with all documents to T.P.A./ OP No.2 through speed post, all the documents as well IPD (impatient Department) documents/papers were sent to TPA through Speed post dated 05.09.2010 and 22.12.2010, despite his repeated request and visits for consider his claim, nothing was done by the OP Co., hence this complaint.
2. Complaint has been contested by OP. In its written statement, OP stated that as regard the claim was closed as the complainant has not  replied of the letter dated 27.09.2010 and 22.12.2010. It is further stated that  the complainant choose to take treatment from the hospital which is not registered for 15 beds which is not in accordance with the terms of contract and prayed for the dismissal of the complaint.
3. Both the parties have filed their evidences by way of affidavit. In order to prove his case the complainant filed his evidence by affidavit and also filed written submission. The complainant placed on record, copy of Happy Family Floater Policy Schedule Mark-Annexure-A. Copy of intimation with e-mail dated 01.09.2010 Mark-Annexure-B,  copy of letter dated 10.09.2010 with postal receipt send to OP-2 Mark- Annuxure-C, Copy of claim form Mark-Annuxure-D, copy of details of expenses with discharge summary and physicians progress note and orders Mark- Annuxure-E, copy of registration certificate of Hospital Mark Annxure-F. The OP had proved and filed the copy of  medical policy, intimation letter dated 10.09.2010, Copy of claim query letter dated 27.09.2010, copy of claim first reminder dated 22.12.2010 and copy of claim file closed/no claim letter dated 09.02.2011.
4. We have heard the learned counsel for parties and perused the record. It is not in dispute that the complainant has taken a  Medical Insurance/Happy Family Floater Policy No.215100/48/2010/3470 valid from 17.02.2010 to 16.02.2011, with Silver Plan, and premium was paid  of  Rs.8,000/- on 17.02.2010 for a  sum insured of an amount of Rs.3,00,000/- for himself and his wife, nor is it in dispute that the wife of the complainant was admitted in the hospital during subsistence of the policy. The policy was, therefore, valid on the date of the hospitalization. It is the case of complainant that the complainant filed the  claim with OP Insurance Co. as his wife/one of the member of health policy was hospitalized in Ekansh Nursing Home for the treatment of fever with Thrombocytopenia and on 30.08.2010 and discharged on 06.09.2010.  Thereafter submitted a claim of Rs.52,687/- along with all documents to T.P.A./ OP No.2.  but  nothing was done by the OP Co. and the claim was closed on `No CLAIM`on 09.02.2011 on arbitrarily & flimsy ground.
5. OP filed WS stated that the complaint is not maintainable as there was violations of condition No.2.1 of the insurance contract since the complainant choose to take treatment from the hospital which is not registered for 15 beds in accordance with terms of contract.
6. We have perused the condition 2.1 of the insurance contract and terms & conditions of the insurance policy in respect of the medical health policy. The policy wording of condition No.2.1 (i) of the said policy while covering treatment, state; Hospital/Nursing Home means any institution in India established for indoor care and treatment of sickness and injuries and which either; a) has been registered either as a Hospital or Nursing Home with the local authorities and is under the supervision of a registered and qualified Medical Practitioner OR  b) should comply with the minimum criteria as under: I) it should have at least 15 in-patients beds ii) fully equipped operation theatre of its own wherever surgical operations are carries out: iii) fully qualified Nursing staff under its employment round the clock: iv) fully qualified Doctors should be in charge round the clock. On perusal of registration certificate of Hospital Mark-Annxure F. it seems that hospital/Nursing home  from where the wife of the complainant  take treatment falls under clause (a) of the term of the policy (registered with the Directorate of Health Services, Govt. Of NCT of Delhi). In the absence of such an exclusion, the OP/insurance company will have to indemnify the insured hospitalization bill. The OP insurance company failed to placed on record the D-panel list/letter of Ekansh Nursing Home, 122-123, Shahbad Daulat Pur, Dehi-110042, which shows that the treatment taken by the complainant during this period was not covered under the policy, hence in our view the repudiation was unjustified.
7. In view of above discussion, we are of the considered view that the claim for the the period from 30.08.2010 to 06.09.2010 a sum of Rs.52,687/-, the repudiation of the claim by OP-1 is unjustified,  Hence, we  allowed the present complaint with following directions to OP-1:-

1. .    Pay to the complainant sum of Rs. 52,687/- (Rupees Fifty  Two Thousand Six Hindered Eighty Seven only) along with                 6%    interest from the date of filing of complaint i.e.  25.03.2011 till realization.
2.     Pay to the complainant a sum of Rs.10,000/-(Rupees Ten Thousand Only)  towards compensation which will also include                the cost of litigation.

If OP-1 is fail to pay the said amount within stipulated time it    shall be liable to pay interest on the total awarded amount @  9% PA, from the date of this order.

Order accordingly. Office is directed to send one true copy of     this order to the parties/speed post in accordance with the    rules. This final order be sent to server (www.confonet.nic.in).   Thereafter, file be consigned to record room.

Announced on this   29^th  Day of   March , 2022.

 

 

(POONAM CHADHARY)

President

 

 

           (BARIQ AHMAD)                                      (ADARSH NAIN)       

             Member                                                              Member