O R D E R
K.S. MOHI, PRESIDENT
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 had taken a mediclaim policy (Happy Family Floater) bearing No.271500/48/2012/5530 for the period from 17.02.2012 to 16.02.2013 from the O.P-1. On 06.05.2012 complainant’s father Sh. Ishwar Persad Goel was admitted to Ekansh Nursing Home for the operation of left knee (Post Traumatic Meniscus Tear with Haemarthrosis) and was discharged on 08.05.2012. It is further alleged that complainant sent an intimation letter about hospitalization of his father to the O.P-2. It is alleged that complainant submitted his claim for Rs.62,758/- along with all the original medical bills to the O.P-2. It is further alleged that O.Ps have not given any claim to the complainant. It is alleged that complainant send various reminders and orally requested the O.Ps to reimburse the claim amount but all in vain. Complainant has also sent a legal notice dated 24.09.2012 but of no avail. It is alleged that complainant shocked to note that the O.P vide his letter dated 15.02.2013 addressed to the complainant that “query reply received on 24.12.2012 but it is not sufficient to process the claim kindly provide policy copy for period 2008-2009”, thereby overlooking the contents of the complainant letter dated 21.12.2012 wherein he has specifically stated “I am covered under mediclaim since 17.02.2009 so I have only 3 policies for the past and one for the current years”. It is further alleged that till date the letter dated 15.02.2012 has not received by the complainant by post. On these facts complainant prays that O.Ps be directed to pay the mediclaim amount of Rs.62,758/- alongwith interest and also to pay cost and compensation as claimed.
2. O.P-1 appeared and filed its written statement. In its written statement O.P-1 has not disputed that complainant had taken policy refer to above. It is alleged that the present claim of the complainant has been repudiated as “No Claim” by the O.P-2 on the basis of the documents supplied by the complainant since as per the clause 4.1 of the terms and conditions of the policy i.e. as per the said exclusion clause, during the period of insurance cover the expenses on treatment of the following ailments/ diseases/ surgeries for specified periods are not payable if contracted and/ or manifested during the currency of the policy and the treatment of Age related Osteoarthritis and Osteoporosis is not payable for first 4 years. It is further alleged that as per the letter dated 15.02.2013 of the O.P-2 the complainant has failed to provide the copy of the policy for period 2008-2009 and since the present claim of the complainant is only payable for the treatment of ailment in question after waiting period of 4 years after the inception of the policy the O.P-2 has rightly repudiated the claim of the complainant as “No Claim” vide letter dated 15.02.2013. Dismissal of the complaint has been prayed for.
3. Complainant has filed his affidavit in evidence reiterating all the facts as mentioned in the complaint and has proved documents exhibited as Ex. CW-1/1 to CW-1/14. On the other hand Shri Brij Mohan, Sr. Divisional Manager has filed affidavit in evidence on behalf of O.P-1 (OIC) 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 submissions of Ld. Counsels for the parties.
5. In the present case the real controversy is as to whether the repudiation by the O.P by pressing into service clause 4.1 of terms and conditions of the policy i.e. exclusion clause where by certain ailments/ diseases/ surgeries for specified periods are not payable and that the treatment of Age related diseases was not payable for first 4 years, was justified and valid. The O.P rejected the claim because his disease suffered by the insured was hit by clause 4.1. It is now well settled law that terms and conditions including the exclusion clause shall be applicable only when the same was part and parcel of the insurance policy or the insured was specifically made aware of said terms and conditions by the O.P. I have seen the insurance policy which does not find mention of terms and conditions. Rather the terms and conditions is a separate document which obviously was never supplied to the insured at the time of execution of the policy. 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.
6. Keeping in view the discussion above the O.Ps repudiate the claim on frivolous grounds, therefore, deficiency in service. We award a sum of Rs.62,758/- with interest @ 6% from the date institution of the complaint till payment, the further award of Rs.5,000/- towards harassment mental agony loss of time which will also include cost of litigation.
Copy of this order be sent to the parties as per rules.
Announced this 02nd day of April, 2016.
(K.S. MOHI) (SUBHASH GUPTA) (SHAHINA)
President Member Member
A.G.
