O R D E R
K.S. MOHI, PRESIDENT
The complainant has filed the present complaint against the O.P u/sec. 12 of Consumer Protection Act, 1986. The facts as alleged in the complaint are that the complainant had taken a mediclaim policy (Happy Family Floater Policy) bearing No.360701/48/2009/8500000169 valid for the period from 20.04.2009 to 19.04.2010 from the O.P. On 02.10.2010 complainant’s son namely Vishal suffered with high fever i.e. Dengue and was operated upon for his illness in Hitaishi Medical Centre, Rohini, Sec-8, Delhi and was discharged on 07.10.2010. It is alleged that complainant incurred a total sum of Rs.16,394/- for treatment of her son. It is further alleged that intimation was given to Alankit Health Care TPA Ltd., 2E/21 Jhandawalan Extn. New Delhi on 20.10.2010 and submitted all the documents to reimbursement of the amount which was spent by the complainant for treatment of her son. It is alleged that claim was rejected by the O.P on the ground that there was delay in submission of claim and claim was not payable for the first two years of taking the policy. It is alleged that complainant orally requested and sent reminders to the O.P for reimbursement the above said amount but all in vain. On these facts complainant prays that O.P be directed to pay the mediclaim amount of Rs.16,394/- alongwith interest and also to pay cost and compensation as claimed.
2. O.P appeared and filed its written statement. In its written statement O.P has not disputed that complainant had taken policy referred to above. It has also not been disputed that complainant was admitted in Hospital for treatment of Dengue. It is alleged that the complainant had an Individual Mediclaim Policy No. 360701/48/10/8590000482 under policy No.360701/48/10/8500000210 issued from Branch Office and as per the claim son of the complainant was allegedly admitted in Hitaishi Hospital, Rohini, Delhi on 02.10.2010 and was discharged on 07.10.2010. It is further alleged that the claim was referred to the Alankit Health Care TPA Ltd., (Third Party Administrator) who after going through the documents and Hospital treatment record and discharge summary of the complainant, informed the O.P vide letter Ref. TPA/BA/2010/12/141421 DATED 14.12.2010, that the claim of the complainant has been found inadmissible as per the terms and conditions of the policy. It is alleged that policy is under second year i.e. 20.04.2009 whereas the complainant was diagnosed as a case of ‘Fibroid Utreus-Abdominal Hysterectomy’ which is excluded during first two year of the policy, therefore, the claim falls under the exclusion clause 4.3 of the terms and conditions of the policy. Dismissal of the complaint has been prayed for.
3. Complainant has filed her affidavit affirming the facts alleged in the complaint. On the other hand Shri Pyarelal, Assistant Manager has filed affidavit in evidence on behalf of O.P testifying all the facts as stated in the written statement. Parties have also filed their respective written submissions.
4. We have carefully gone through the record of the case and have heard submission of complainant and Ld. Counsel for the O.P.
5. In the instant case the dispute is as to whether the O.P is justified in repudiating the claim submitted by the complainant on the basis of exclusion clause of terms and condition of insurance policy. It has been submitted by the complainant that she was not provided with the terms and conditions of the policy and now the insurance company is estopped from taking shelter under the said terms and conditions. The case of the O.P on the other hand is that terms and conditions are part and parcel of the policy and have to be applied while processing the claim of the complainant. It is true that O.P has nowhere stated as to when and in which manner the said terms and conditions were supplied to the complainant. Obviously the terms and conditions do not form part of the policy rather is a separate full-fledged document which ought to have been furnished to the insured at the time of execution of insurance policy. The complainant who was never aware of the said terms and conditions, cannot be said to be bound by the said terms and conditions. In case titled IV (2014) CPJ 14A (CL) HAR. Oriental Insurance Co. Ltd. Vs Vivek Rekhan, the claim filed on the basis of mediclaim policy was repudiated by the insurance company on the basis of exclusion clause. The court held that the insurance company vaguely denied without pointing out as to in which manner and on which date terms and condition were supplied to the complainant. Therefore, unless terms and condition have been supplied to the complainant before taking a policy, exclusion clause cannot be enforced.
7. The aforesaid discussions clearly demonstrate that there was deficiency in service on the part of the O.P by repudiating the claim on flimsy ground. Therefore, we direct the O.P to pay a sum of Rs.16,394/- to the complainant along with interest @ 6% from the date institution of the complaint till payment, the further award of Rs.3,000/- towards harassment mental agony loss of time and Rs.1,000/- towards litigation cost.
Copy of this order be sent to the parties as per rules.
Announced this 22nd day of December, 2015.
(K.S. MOHI) (SUBHASH GUPTA) (SHAHINA)
President Member Member
