Delhi

New Delhi

CC/756/2013

Ashok Kumar Gupta - Complainant(s)

Versus

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

02 Jun 2016

ORDER

 

 

CONSUMER DISPUTES REDRESSAL FORUM-VI (DISTT. NEW DELHI), ‘M’ BLOCK, 1^STFLOOR,

VIKAS BHAWAN, I.P.ESTATE,

NEW DELHI-110002.

 

Case No.CC/756/13                                                                                                               Dated:

 

In the matter of:

Mr. ASHOK KUMAR GUPTA,

R/O NS-16, IST FLOOR,

MINYA WALI NAGAR,

WEST DELHI,

NEW DELHI-110087.

                 

         ……..COMPLAINANT

 

VERSUS

 

M/S. THE ORIENTAL INSURANCE CO. LTD.

(THROUGH ITS CHIEF MANAGAER/REGIONAL MANAGER)

DRO-II, SCOPE MINAR TOWER, LAXMI NAGAR,

DELHI-92

 

………. OPPOSITE PARTY

 

ORDER

 

PRESIDENT: S K SARVARIA

 

Complainant is the medi-claim policy holders of OP Co. vide policy No.271500/48/2013/2726 w.e.f. 4.10.2012 to 3.10.13.

It is alleged by the Complainant that on 3/3/13 the son of the Complainant sustained injuries i.e fracture mandible due to an incidence happened at home, he was immediately admitted to Sparsh hospital by his friends, and then he (Complainant) and his other relative shifted him to Sri Bala Ji Medical Institute, Paschim Vihar for better treatment.

It is alleged by the Complainant that OP Co. denied the cash less facility to him and as such he made the payment of Rs.1,02,000/- to the hospital at the time of discharge of his son i.e.  on 1..4.13

It is further alleged by the Complainant that OP failed to settled his genuine claim ever after submitting the relevant documents to it, and has repudiated the same by taking the shelter of condition 5.9 of the policy term and conditions.

The Complainant therefore, approached this Forum for the redressal of his grievance.

 Notice of the Complainant was sent to the OP since non-appeared on behalf of OP, it was ordered to be proceeded with ex-parte on 17.7.2014.

Complainant filed its ex-parte evidence, by way of Affidavit.  He has placed on record copy of the policy, discharge summary, medical bills, other medical treatment record as well as the copy of repudiation letter dated 22.5.13, to prove his case.

Shri Surjit Keshari Adv. filed Vakalatnama on behalf of OP on 12.2.2016 and stated that he will seek instructions to settle the case.

OP Insurance Co. fails to settle the case even after taking two adjurnments; hence after hearing both the parties, the aforesaid case was reserved for orders.

Ld.Counsel of the Complainant has stated that the Complainant was the medi claim policy holder of OP Co. since 2010 and was regularly paying the premium.  It is further stated by the Counsel for the Complainant that son of the complainant was admitted in Sri Bala ji Action Medical Institute on 31.3.16 and was diagnosed with the problem of Fracture Mandible left side, He was earlier diagnosed with the same problem by Sparsh Hospital also but for better treatment Complainant had shifted his son to Sri Balaji Action Medical Institute, Paschim Vihar.

It is  further stated by the counsel for the Complainant that OP Co. had repudiated his genuine claim on the ground which reads as below:-

“Section 5, Conditions (5.9)-Fraud/Misrepresentation/Concealment.  The company shall not be liable to make any payment under this policy in respect of any claim if such claim be in any manner intentionally or recklessly or otherwise misrepresentated or concealed or non disclosure of material facts or making false statements or submitting false bills whether by the insured person or institution /organization on his behalf.  Such action shall render this policy null and void and all claims hereunder shall be forfeited.  Company may take suitable legal action against the insured person/institution/organization as per law”.

He had taken us through the policy documents Page 2 which states as under:-

“The policy shall pay for hospitalization expenses for medical/surgical treatment at any Nursing Home/Hospital in India as an in-patient defined in the policy”

The Counsel for the Complainant had also taken us on OPD paper of Sparsh Hospital where the patient took first aid on 31.3.16, the perusal of the same makes it clear that the patient was diagnosed with the problem of Fracture Mandible left side.  He had also drawn our attention to the certificate given by the treating Doctor of Sri Balaji Action Medical Institute.

It is stated by the Ld.Counsel for the Complainant that when the OP Co. had undertaken to pay the hospitalization expenses of the Complainant vide its policy No. 271500/48/2013/2726 the repudiation made by it was unjustified.

The Ld.Counsel of the OP on the other hand has contended that as there is the gross variation of the facts as per the statements, patient is fallen from stairs and as per Sparsh Hospital OPD slip is a case of RTA.  Hence, the repudiation is justified.

We are not in agreement with the contention of the counsel of the OP.  Due to mere variation in statement OP had repudiated the claim of the complainant, but failed to consider the other relevant documents, such as the Diagnosis. Made by both the hospitals, treatment taken by the patient, the certificate issued by the treating doctors.

In view of the above discussions and the documents placed on record, we are of the considered opinion that OP ought  not to have repudiated the claim of the complainant under exclusion clause No.5.9 of the policy term and condition which is not applicable in complaint case.  Rather should also consider the medical record. Certificate of the treating doctor, while repudiating the same.

          We, therefore of the considered opinion that ground of repudiation is unjustified.

We, hold OP Co. guilty of deficiency in service and direct it as under:-

1) Pay to the complainant a sum of Rs.1,02,002/-  along with 10% interest from the date of filing of complaint i.e. 22.8.13 till payment.

2) Pay to the complainant a sum of Rs.10,000/- for  mental agony trauma suffered by her.

3) Pay to the complainant a sum of Rs..5,000/- as a cost of litigation.

The order shall be complied with within 30 days of the receipt of the copy of the order. If the said amount is not paid by the OP within a period of one month from the date of receipt of this order, the same shall be recovered by the complainant along with simple interest at the rate of 10% per annum from the date of this order till recovery of the said amount of Rs. 15,000/–. This final order be sent to server (www.confonet.nic.in ). A copy each of this order each be sent to both parties free of cost by post.

File be consigned to the record room.

Pronounced in open Forum on 02.06.2016.

 

 

(S K SARVARIA)

 PRESIDENT

 

 

(H M VYAS)

MEMBER