O R D E R
SUBHASH GUPTA, MEMBER
The complainant has filed the present complaint against the O.P u/sec. 12 of Consumer Protection Act, 1986. The brief facts as alleged in the complaint are that the complainant had taken an insurance policy (Happy Family Floater Policy) for the period from 19.09.2011 to 18.09.2012 bearing No.272302/48/2012/1011 from the O.P’s agent. The said policy assured to cover accidents and various diseases as represented to the complainant by the agent of the insurance company i.e. the O.P. It is alleged that unfortunately on 13.06.2012 complainant suffered from acute pain and headache and was admitted in St. Stephen’s Hospital, Delhi for his treatment and was discharged on 18.06.2012. It is further alleged that the complainant after discharge from the hospital immediately filed a claim for reimbursement for medical expenses incurred by him amounting to Rs.55,990/- for his treatment. It is alleged that the complainant submitted all the original medical Hospital bills etc. with the O.P for reimbursement of the said amount which was paid by the complainant for treatment. It is further alleged that O.P has not given any claim to the complainant. It is alleged that complainant orally requested the O.P to reimburse the above said amount but of no avail. It is further alleged that on 21.09.2012 complainant was surprised to receive a letter from O.P vide which his claim was repudiated for the reasons as per clause 4.3 and 5.5. On these facts complainant prays that O.P be directed to pay the mediclaim amount of Rs.55,990/- with interest @ 24% p.a. 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 refer to above. It is alleged that the said policy was subject to certain conditions, clauses, warranties and endorsement and the claim of the complainant is not payable under the exclusion clauses 4.3 and 5.5 of the terms and conditions of the policy which reads as under:
4.3 “The expenses of following elements disease surgeries for specified period are not payable if contracted and or manifested during the currency of the policy.”
5.5 “As final claim alongwith original of hospital bills, cash memos, reports, claim form and list of documents should be submitted to the TPA within 7 days of discharge from the hospital and nursing home.”
It is further alleged that the O.P repudiated the claim of the complainant vide letter dated 21.09.2012 which was admittedly intimated to the complainant. It is alleged that under the terms, conditions and exclusion of the policy the claim of the complainant was held to be not payable. 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 Rajiv Chopra, Divisional Manager has filed affidavit in evidence on behalf of O.P (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 as well as written submission filed by both the parties.
5. In the instant case the dispute is as to whether the O.P was 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 he 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. 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.54,625/- to the complainant alongwith interest @ 6% from the date institution of the complaint till actual payment. We further award a sum of Rs.5,000/- towards harassment, mental agony as well as loss of time which will also include cost of litigation.
Copy of this order be sent to the parties as per rules.
Announced this 26th day of May, 2016.
(K.S. MOHI) (SUBHASH GUPTA) (SHAHINA)
President Member Member
