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 from the O.P-1 in the year 2003. It is alleged that the policy was renewed from time to time and at the relevant time the policy bearing No.271500/48/2012/3928 for the period from 17.11.2011 to 16.11.2012. On 15.01.2012 complainant suffered with some health problem i.e. pain in the abdomen and he was operated upon for his illness in Sundar Lal Jain Hospital, Ashok Vihar Phase-III, Delhi and was discharge on 17.01.2012. It is alleged that complainant had lodged claim with the O.Ps and the said claim of the complainant was processed and passed by the O.Ps. It is further alleged that after his discharge from the hospital the complainant had to visit the attending medical practitioner for follow up treatment. It is alleged that as per medical advice of the attending medical practitioner the complainant got admitted in Sunder Lal Jain Hospital, Ashok Vihar Phase-III, Delhi for follow up treatment as day care procedure. It is further alleged that complainant incurred a total sum of Rs.11,364/- for his treatment. It is alleged that the complainant submitted all the original medical Hospital bills etc. with the O.Ps to reimbursement of the said amount which was paid by the complainant for his treatment. It is further alleged that O.Ps have not given any claim to the complainant. It is alleged that complainant orally requested the O.P-1 to reimburse the above said amount but all in vain. Complainant has also sent a legal notice dated 01.05.2012 but of no avail. It is alleged that complainant received a letter dated 29.02.2012 from the O.P-2 whereby alleging that the claim of the complainant was rejected on the ground that late intimation. On these facts complainant prays that O.Ps be directed to pay the mediclaim amount of Rs.11,364/- 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.Ps has not disputed that complainant had taken policy refer to above. It is alleged that the complainant was admitted in the Hospital on 30.01.2012 and discharged on the same day. It is further alleged that complainant had intimated the TPA and document submission was done on 13.02.2012. Hence there is delay of 12 days in intimation and 5 days in submission of the claim. It is alleged that as per clause 5.4 of the policy condition an intimation should be given within 48 hrs of admission or before discharge from the hospital unless waived in writing and as per clause 5.5 of the policy, claim documents should be submitted to company within 7 days of discharge from the hospital. Dismissal of the complaint has been prayed for.
3. Complainant has filed his affidavit affirming the facts alleged in the complaint and has proved documents exhibited as Ex. CW-1/A to CW-1/J. On the other hand Shri Brij Mohan, Sr. Divisional Manager has filed affidavit in evidence on behalf of O.Ps (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 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 the intimation of hospitalization was not given in time to the O.P. That there is delay of 12 days in intimation and 5 days in submission of the claim. It has been further stated on behalf of O.P that as per clause 5.4 of policy, intimation should be given within 24 hours of admission or before discharge from the hospital, unless waived in writing by the O.P.
6. I 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 which require submission of claim within 48 hours of admission were supplied to the insured. The affidavit of evidence filed on behalf of insurance company indicates that the copy of the terms and conditions was exhibited as Ex.R1W1/1 but no such document is existing on the judicial file. It means that insurance company though relying upon exhibited as Ex.R1W1/3 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 O.Ps repudiate the claim on frivolous grounds, therefore, deficiency in service. We award a sum of Rs.11,364/- 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.3,000/- towards litigation cost.
Copy of this order be sent to the parties as per rules.
Announced this 16th day of December, 2015.
(K.S. MOHI) (SUBHASH GUPTA) (SHAHINA)
President Member Member
