Delhi

New Delhi

CC/266/2011

Rakesh Sejwal - Complainant(s)

Versus

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

07 Apr 2015

ORDER

CONSUMER DISPUTES REDRESSAL FORUM-VI

(DISTT. NEW DELHI), ‘M’ BLOCK, 1^STFLOOR,

VIKAS BHAWAN, I.P.ESTATE,

NEW DELHI-110002.

 

Case No.CC/266/11                                Dated:

In the matter of:

Rakesh Sejwal,

R/o 264, Chirag Delhi, New Delhi-110017

……..COMPLAINANT

       

VERSUS

 

1. Oriental Insurance Co. Ltd.,

        573, Chirag Delhi, New Delhi-110017

 

2. Oriental Insurance Co. Ltd.,

        Oriental House, A-25/27,

        Asaf Ali Road, New Delhi

                                         ……..OPPOSITE PARTIES

 

ORDER

Member: Ritu Garodia

The above facts of alleged deficiency are that the Complainant took a floater medi claim policy for the period 07.02.07 to 06.02.08, which was renewed from 07.02.08 to 06.02.09. His wife was hospitalized in Pushpawati Singhania in June 2008, bill of Rs.22,171/- along with discharge summary is annexed subsequently. She has to undergo skin treatment and had to bear expenses for Rs.10,291/ (Rs.4,492/- + Rs.4,373/- + Rs.1,426/- bills annexed). She again underwent treatment in Surya Medical centre on 04.02.09 but no bills are annexed.

OP in its reply has admitted the policies but alleged that repudiation was done under clause 4.3 where calculus disease excluded for first 2 years. It also stated that clause 2.3 states that “Expenses on hospitalization are admissible only if hospitalization is for minimum period of 24 years. OP has also referred to Discharge summary issued by Pushpawati Singhania Research Institute and ultrasound dated 30.01.09   wherein it was found that Complainant was suffering from Calculus. OP has reiterated that discharge summary discloses that complainant’s wife was diagnosed for B/L small multiple renal calculi.

Careful consideration to documents annexed reveals that complainant 1^st hospitalization occurred in June 2008 and discharge summary of Pushpawati Singhania hospital discloses that she was suffering from pan gastritis which means gastritis of whole stomach. She has colonoscopy which shows erosion in cecum (large intestine). The said discharge summary also states that “CECT should B/L multiple non obstructive renal calculi. That leads to conclusion that OP with mala fide intention left out words “non obstructive” when reproducing the diagnoses from discharge summary. Complainant was hospitalized for pan gastritis as well as some erosion in intestine. There are some calculi (stones) which are non-obstructive. The OP has referred to exclusion clause 4.3 which is calculus disease (disease relating to stones). As this hospitalization was not for calculus. OP should have settled the claim. As for the claim of skin diseases, there was no hospitalization; OP is not bound to settle the claim. Report place by OP dated 30.01.09 is not related to any claim made by complainant.

We, therefore, hold OP guilty of deficiency in service and direct OP to pay Rs.22,171/- with interest @ 9% from date of claim till payment. We also award Rs.20,000/- as compensation towards harassment for arbitrarily repudiating the claim resulting in mental agony and inconveniences.

The order shall be complied within 30 days of the receipt of the copy of the order; otherwise action can be taken under Section 25 / 27 of the Consumer Protection Act.

File be consigned to record room.

Copy of the order be sent to the parties free of cost.

 

        Pronounced in open Court on 07.04.2015.

 

                   

(C.K.CHATURVEDI)

PRESIDENT

 

(S.R. CHAUDHARY)                 (Ritu Garodia)

MEMBER                                  MEMBER