Delhi

New Delhi

CC/820/2012

Anisha Raj Arora & anr. - Complainant(s)

Versus

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

29 May 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/820/12                                                                                                                                                                                Dated:

In the matter of:

MS. ANISHA RAJ ARORA & ANR.

W/O SHRI RAJ KUMAR ARORA,

8/13, SOUTH PATEL NAGAR,

NEW DELHI

 

MS. SAMIDHA RAJ ARORA & ANR.

D/O SHRI RAJ KUMAR ARORA,

8/13, SOUTH PATEL NAGAR,

NEW DELHI

 

                   ……..COMPLAINANT

         

VERSUS

THE ORIENTAL INSURANCE COMPANY LTD & ORS,

ORIENTAL HOUSE, A-25/27, ASAF ALI ROAD,

NEW DELHI-110001

 

………. OPPOSITE PARTIES

 

 

 

ORDER  [ ORAL]

 

Date of Arguments :13.05.2015

Member: Ritu Garodia

Present : Counsel for complainant,  OP-1 & III.

Arguments  heard.

It is a complaint case pertaining to repudiation of the claim policy by OP.  Complainant had taken Floater Medi-claim Policy bearing No.215400/48/2012/1805 for her family and herself. The insured sum was Rs.4,00,000/- covering the  period from 1.7.2011 to 3.6.2012.  The complainant was hospitalized on 21.4.12 for Urethral Dilatation↓LA and pre and post surgical test/procedure were conducted.  A claim for reimbursement was made and repudiated by OP on 29.6.14 under the exclusion clause 2.3 of the policy.

OP in its WS has reiterated clause 2.3 of policy which pertains to hospitalization period.  OP has further alleged that ‘Urethral Dilatation↓LA’ did not entail any admission and therefore the claim was repudiated.  Perusal of the record reveals that section(A) of the said clause 2.3 present exclusion clause which states that hospitalization period for 24 hours will not apply for specific treatments taken in the Network Hospital Nursing Home.  The list of treatment includes surgery of Urinary system.  Bare reading of section(A) clause 2.3 shows that the exclusion is squarely applicable in the present case.  There was no requirement of 24 hours hospitalization in this case. 

We, therefore, hold OP guilty of imperfection of service by repudiating the claim on frivolous and  flimsy grounds.  OP is directed to settle the claim of the complainant for Rs.28,357/- with 9% interest from date of claims till realization.  OP is also directed to pay Rs.10,000/- as compensation for harassment, and mental trauma caused in not settling the claim inclusive of  litigation expenses.

The order shall be complied with 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 29.05.2015.

 

        File  consigned to record Room.

 

 

 

(C.K.CHATURVEDI)

PRESIDENT

 

 

 

(S.R. CHAUDHARY)         (RITU GARODIA)

MEMBER                          MEMBER