O R D E R
SUBHASH GUPTA, MEMBER
The complainant has filed the present complaint against the O.Ps u/sec. 12 of Consumer Protection Act, 1986. The facts as alleged in the complaint are that the complainant is a student and his father is credit card holder of Citi Bank having credit card NO.5546379498694007. It is alleged that the complainant purchased a mediclaim policy from OP-1 through OP-2 on 1.3.2010 for a claim of Rs.1,50,000/- valid for the period w.e.f. 01.03.10 to 29.03.12. On 02.07.2011 complainant suffered with some health problem i.e. fever, vomiting and throat pain and he was admitted to St. Stephen Hospital which is in the panel of hospital of the Insurer i.e. OPs on 03.07.2011 and was discharged on 08.07.2011. It is alleged that initially on 5.7.2011 an amount of Rs.4,000/- for complainant treatment was approved by OP-3 but later the same was rejected. It is alleged that OP-3, without considering terms and conditions of the policy and giving attention to the doctor advice of their hospital rejected the approved amount with remarks that this ailment is not payable for the first two years of taking the policy. It is alleged that one of the doctors who treated the complainant has issued the certificate stating that the complainant was diagnosed to have acute sinusitis which is acute problem. It is also alleged that the sinusitis is also not in the list of the diseases of the OPs which disentitle the complainant to get the claim. It is alleged that due to said conduct of the OPs, the complainant has undergone great mental tension, pain and agony. That, therefore, there is a deficiency in services on the part of OPs. On these facts complainant prays that O.Ps be directed to pay the claim amount of Rs.21,907/- alongwith interest and also to pay cost and compensation as claimed.
2. O.Ps appeared and filed their written statement. In its written statement O.P-1 has not disputed that complainant had taken policy referred to above. It is alleged that the complainant was admitted in the Hospital on 03.07.2011 and was discharged on 08.07.2011. It is further alleged that complainant was diagnosed to have been suffering from acute sinusitis and was diagnosed for the first time, therefore the claim in r/o aforesaid ailment was not payable within two years as per terms and condition of policy and claim was repudiated. It is alleged that the present complaint involves the complex question of law and facts which cannot be decided on summary basis. It is alleged that OP-2 does not provide any insurance services and he is only authorized to act as a corporate agent of OP-1. It is alleged that there is a dispute between the complainant and OP-1 & 3 and OP-2 is not involved in any manner in the present complaint, therefore OP-2 has no role to play in the present complaint. Dismissal of the complaint has been prayed for.
3. Complainant has filed his affidavit affirming the facts alleged in the complaint. On the other hand Shri S.K.Soui, Dy. Manager(OP-1) and Sh. Pradeep Bhalla, Authorised Signatory(OP-2) have filed affidavit in evidence on behalf of OPs 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 Ld. Counsel for the complainant.
5. In this case the medical policy is not in dispute. The O.P has also not disputed the hospitalization of the complainant. The only ground for rejection of the claim is that complainant was diagnosed to have been suffering from acute sinusitis and was diagnosed for the first time, therefore the claim in r/o aforesaid ailment was not payable within two years as per terms and condition of policy and claim was repudiated by the O.Ps.
6. We have seen the contents of insurance policy which provides that policy is subject to conditions, clauses, warranties, endorsements as per forms attached. The policy itself does not incorporate any of the condition relied upon by the insurance company. The insurance policy has also not placed on record nor any cogent evidence is led as to when and in which manner the said terms and conditions. The affidavit of evidence filed on behalf of insurance company indicates that the copy of the terms and conditions but no such document is existing on the judicial file. It means that insurance company though relying upon but has not proved the same on record. In the absence of such documents no credence can be given to the plea taken by the O.P. Even otherwise 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. Keeping in view the discussion above the OP-1 & 3 repudiated the claim on frivolous grounds, therefore, have caused deficiency in service. We award a sum of Rs.21,907/- 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.2,000/- towards litigation cost payable by OP-1 & 3 jointly and severally.
Copy of this order be sent to the parties as per rules.
Announced this 29th day of December, 2015.
(K.S. MOHI) (SUBHASH GUPTA) (SHAHINA)
President Member Member
