Delhi

New Delhi

CC/938/2012

Poonam Sharma - Complainant(s)

Versus

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

08 Jun 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/938/12                                                                                                                                                                          Dated:

In the matter of:

1. Smt. Poonam Sharma,
2. Sh. Akash Sharma

Both R/o: X-5133, Gali no.2,

Kaushik Puri, Old Seelampur,

Gandhi Nagar, Delhi-110031

……..COMPLAINANT

       

VERSUS

 

1. The Oriental Insurance Co. Ltd.,

Direct Agent Branch-1

60, Janpath, New Delhi

Through its Branch Manager,

 

2. Sh. Ravinder Kumar Sharma,

Development Officer,

Oriental Insurance Co.,

Divisional Office no.3,

4E/14, Zad Bhawan, Jhandewalan Extn.,

New Delhi-110055

 

3. MD India Health Services (TPA) Pvt. Ltd.,

Plot no.18/13, WEA, GF, Ganga Plaza,

Karol Bagh, Delhi-110085

 

                                         ……..OPPOSITE PARTIES

 

 

ORDER

Member: S.R Chaudhary

 

The Complainant had taken a floater policy from OP2 on 19.07.10 as per annexure “A”. Suddenly complainant went under treatment for “Cholecystectomy” at Sir Ganga Ram Hospital and request form was submitted for approval of Rs.52,000/- to OP2 on behalf of OP1 as cashless facility but it was declined under clause 4.3 medical policy. Thus, complaint was filed.

As per reply of OP and evidence, the plea taken in para3 under shelter of clause 4.3 which is reproduced as under:

If these diseases are pre-existing at the time of proposal the execution no.4.1 for pre-existing condition shall be applicable in such cases.

 

	Benign ENT disorders and surgeries i.e. Tonsillectomy, Adenoldectomy, Mastoldectomy, Tympnoplasty etc.	I year
	Polycystic ovarian diseases	2 years
	Surgery of hernia	2 years
	Surgery of hydrocele	2 years
	Noninfective Arthritis	2 years
	Undescendent Testes	2 years
	Cataract	2 years
	Surgery of bengin prostatic hypertorphy	2 years
	Hysterectomy for menorrhagia or fibromyoma or prolapseof uterus	2 years
	Fissure/Fistula in anus	2 years
	Piles	2 years
	Sinustitis and related disorders	2 years

 

The above exclusion clause is not connected with above disease of complainant which treatment was due at Ganga Ram Hospital except OP arbitrarily denied the claim according to his own interpretation of clause mentioned above. It clear indicates the deficiency and false assurance given to complainant while policy was issued is cashless.  OP issued a policy but never supplied term and condition to the complainant with policy. OP supplied the terms and conditions when litigation starts at repudiation stage to save his skin whether policy enforces for one year or more, OP never applies application of mind except to decline the claim. Earlier complainant has also taken same policy from United India insurance for the period 2008 to 2009 as per policy exhibit at page 16 placed on record and oriental policy coverage 20.07.10 to 19.07.11 as per annexure R-I, which clearly indicates that policy is already enforced since 2008 to 2011 as per annexure B & C.

Thus, it appears that OP has not evaluated previous policy which is already enforced since 2008 to 2011 and exclusion clause does not fall within the parameter of OP which has been explained above. Despite of facts, OP arbitrarily declined the claim without considering judicial aspects which is clear case of deficiency & breach of contract on the part of OP who deliberately forced the innocent complainant into litigation without any rhyme and reason.

Hence, holding OP deficient and guilty, we direct OP to pay Rs.53,968/- along with 9% interest plus Rs.20,000/- as harassment & litigation expenses.

The order shall be complied within 30 days of the receipt of the copy of the order; otherwise action can be taken against OP 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 08.06.2015.

 

 

 

(C.K.CHATURVEDI)

PRESIDENT

 

 

(S.R. CHAUDHARY)                 (Ritu Garodia)

MEMBER                                  MEMBER