Delhi

North East

CC/210/2014

Syed Ikram Ul Islam - Complainant(s)

Versus

O.I.C. - Opp.Party(s)

03 Dec 2014

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, NAND NAGRI, DELHI-93

 

Complaint Case No. 210/14

 

CORAM:        Hon’ble President Sh. N.A. Zaidi

                        Hon’ble Member Sh. Nishat Ahmad Alvi

                       

In the matter of:

 

Syed Ikram Ul Islam

725-A, First Floor, Main Road

Indra Chowk, Jafrabad

Delhi-110053

                                                                                                                            Complainant                                       

           

Versus

 

1. Oriental Insurance Co. Ltd.

1893, Chandni Chowk

Delhi-110006

Through its Manager also at

 

Oriental House

Post Box NO. 7037

A-25/27 Asaf Ali Road

New Delhi

 

2. Vipul Medi Corp Tap Pvt Ltd.

515, Udyog Vihar Phase-V

Gurgaon

Haryana                                                                          Opposite Parties

 

Order

 

                                                                                      DATE OF INSTITUTION: 03-06-2014

                                                                                      DATE OF DECISION      :  17-04-2015

N.A. Zaidi, President:-

Nishat Ahmad Alvi, Member:-

            As per the complaint complainant a policy holder of OP No. 1 vide Policy No. 271602/47/2013/3 for a sum assured of Rs. 30,000/- (Rupees Thirty Thousand only) being ill was admitted in Holy Child Nursing Home on 26.10.2013  where he was treated till 30.10.2013. Thereafter he was advised complete bed rest. During the treatment he paid Rs. 27,861.65p towards Nursing Home bill and purchasing of medicines. Complainant is a Senior Citizen and due to illness he was unable to move and therefore he could file his claim to the OP only by 12.12.2013. In response of the claim lodged, OP -2 vide its communication dated 24.12.2013 sought some documents and clarifications which the complainant furnished to OP-2 vide his letter dated 02.01.2014. Thereafter, three more letters dated 09.01.2014, 25.01.2014 & 25.02.2014 were received by the complainants from the OP which were also replied and complied with vide complainant letters dated 19.03.2014, 01.05.2014 & 05.05.2014. Thereafter, complainant made number of visits to OP’s office for getting finalising of his claim but OPs by adopting tactics delayed the claim on one pretext or the other.  Complaining that OPs are deciding the claim and harassing him complainant has prayed for the directions to opposite parties to pay insurance claim of Rs. 27,861.65p alongwith interest @24% per annum from the date of lodging of the claim beside Rs. 50,000/- for harassment etc.

            In response to Notice OP-1 by filing his reply pleaded no deficiency on its part hence no cause of action arises against it. There is delay in submission of claim. As per terms of Mediclaim Policy complainant is entitled only for a sum of Rs. 9,600/- against his claim, as recommended by OP-2, which amount complainant has denied to accept and complaint being without cause of action and devoid of merits is liable to be dismissed.

            Complainant by filing his rejoinder to the reply of OP-1 denying the averments made in the reply has reiterated his claim further stating that in recommending the amount of Rs. 9,600/-,  OP-2 has not considered the claim in a sincere manner.

            Both the parties filed their respective affidavits by way of evidence alongwith relevant documents.

            Heard and perused the records.

            Admittedly complainant was a mediclaim policy holder of OP-1, Policy was in force at the time of treatment, treatment took place from 26.10.2013 to 30.10.2013. Though, OP-2 raised the objection of delayed claim but by asking for required documents and clarifications, OPs have impliedly waived the delay. Complainant’s compliance of requirements sought by OP2 are also not denied by OP-2. It is a settled law that insurance policy between the insurer and insured represents a contract between the parties. Thus, the terms of the agreement have to be strictly construed to determine the extent of liability of insurer. Now, therefore, only points to consider remain as to whether OPs kept, avoiding to take decision on the claim and harassing the complainant, for  longer or not and secondly, as to whether the claim passed by OPs was strictly as per terms of policy Mediclaim or not.

Ex-R/2 is a letter written by OP-2 to OP-1 on 25.06.2014. Perusal of this letter show that it was written in response to email of OP-1 dated 24.06.2014. OP-1 sent this email only after notice to it from this Forum. This letter state that “we have approved and settled an amount of Rs. 9600/- against claim amount of Rs. 27,839/-“. This letter nowhere shows that this approval was ever conveyed to the complainant by OP-2. However, OP-1 claims that the said amount was declined by the complainant. But no document to this effect has been filed by OP-1. Regarding entitlement, policy document clearly show that the complainant was entitled for 0.5% per day for room etc in Nursing Home and 15% each for the fee of doctors and tests etc. respectively of the sum assured. In addition to it section 2(b) of the conditions of the policy the complainant was entitled to Rs. 50/- per day from 4^th day of hospitalization. Thus, the estimate given by OP-2 is as per the agreement but Rs. 50/- for which also complainant is entitled to.

Consequently, we are of the opinion that OPs deliberately kept delaying in passing the claim and harassed the complainant and it was only on 25.06.2014, after notice of this Forum that OP-2 passed the claim and not earlier. OP-1 statement that OP-2 has recommended Rs. 9,600/- earlier which the complainant had denied, is baseless since no documentary proof has been filed in support. The denial of Rs. 50/- for 4^th day hospitalization is against the terms of the policy. The entire action of the respondent false within the ambit of unfair trade practices and also amounts to deficiency in service. We allow this complaint. The respondents are directed to pay to the complainant Rs. 9,650/-, jointly and severally, with 12% p.a. interest from the date of filing of this complaint till it is finally paid. We further allow Rs. 5,000/- as compensation for mental pain and agony and harassment and Rs. 3,000/- as cost of litigation, to be paid by the OPs, to the complainant.  

The above amounts shall be paid within 30 days from the receipt of order of this Forum. Failing which the rate of interest on the amount of claim shall be charged @18% p.a.

            Let a copy of this order be sent to each party free of cost as per regulation 21 of the Consumer Protection Regulations, 2005.

File be consigned to record room.

(Announced on 17.04.2015) 

           

           

             

             (N.A. Zaidi)                                                                             (Nishat Ahmad Alvi)       

              President                                                                                           Member