Haryana

Karnal

CC/211/2023

Roshan Lal - Complainant(s)

Versus

Oriental Insurance Company Limited - Opp.Party(s)

Yash Chopra

24 Apr 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                          Complaint No. 211 of 2023

                                                          Date of instt.06.04.2023

                                                          Date of Decision:24.04.2023

 

Roshan Lal Saroha son of Shri Dhiya, age 60 years, resident of village Kiwana, tehsil Samalkha, District Panipat now resident of house no.25/27, New Krishna Nagar, near Aggi Park Ram Nagar, Karnal.

 

                                                 …….Complainant.

                                              Versus

 

1.     Oriental Insurance Company Ltd. SCO 87-88, First floor, Mahila Ashram Complex, near Old Bus Stand Karnal through its Authorized person/Manager.

 

2.     Oriental Insurance Company Ltd. NICCO House 5^th floor, 2 Hare Street Kolkata 700001, through its authorized person.

 

                                                                    …..Opposite Parties.

 

      Complaint u/s 35 of the Consumer Protection Act, 2019

 

Before   Shri Jaswant Singh……President.     

      Shri Vineet Kaushik ………..Member

      Dr. Rekha Chaudhary…Member

 

 Present: None for the complainant.

                                        

                (Jaswant Singh President)

ORDER:                    

 

                Today the case is fixed for consideration on the point of admissibility. None has put into appearance on behalf of complainant. The position remains same on the adjourned date.

                        The complainant has filed the present complaint u/s 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant has taken a health insurance policy for himself and for his other family members since 2002 in continue and the complainant had renewed his said health policy vide, policy no.261300/48/2022/764, for yearly total premium amount of Rs.21,093/- for coverage Rs.5,00,000/-, valid from 07.09.2021 to midnight of 06.09.2022 for the insurance of himself and his wife namely Suman Lata and his son namely Sahil Saroha from the OPs. The said policy is a cashless policy. On 25.07.2022, at about 9.00 a.m., the son of complainant namely Sahil Saroha alongwith his real brother Ankit Saroha coming from Mansarover Furnishing Kunjpura Road to their House on Activa no.Hr-60G-8706. In the meantime, when they reached near Government School, Ram Nagar, Karnal suddenly a Dog come in front of their aforesaid vehicle and due to this they fell down on the road and due to this accident, both received multiple injuries. Complainant got admitted to both at Sanjeev Bansal Cygnus Hospital, Railway Road, Karnal. Complainant submitted the health card and other requisite documents of the aforesaid policy to the concerned hospital for the cashless treatment. The concerned authority of the hospital duly intimated to the OPs for the approval of cashless treatment of Sahil Saroha under the abovesaid policy. The said Sahil Saroha was admitted in the hospital on 25.07.2022 and got discharged on 28.02.2022. The complainant paid Rs.50,000/- cash to the abovesaid hospital. Complainant submitted all the treatment record, receipt of Rs.50,000/-, policy documents alongwith application but the OP no.1 postponed the matter on one pretext or the other. Thereafter, complainant received a letter dated 14.12.2022 whereby the claim of complainant was repudiated on the false and frivolous ground. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

2.             As per version of the complainant, he purchased a health insurance policy from the OPs, covering himself and his family members. On 25.07.2022, sons of complainant namely Sahil Saroha and Ankit Arora met with an accident and due to this accident they suffered multiple injuries. Both are admitted in Sanjeev Bansal Cygnus Hospital, Karnal for treatment. The policy in question was cashless policy. So, concerned hospital intimated the OPs for the cashless treatment of son of complainant Sahil Saroha but OPs did not provide the cashless facility and assured for reimbursement of the claim. Complainant paid Rs.50,000/- on the treatment of his son. After discharge from the hospital, complainant submitted the claim from alongwith all the relevant documents for reimbursement of the claim but OPs refused to pay the same.

3.             The present complaint has been filed on 06.04.2023 and the same was fixed for today i.e. 24.04.2023 for consideration, on the point of admissibility. As per Section 36(2) of the Consumer Protection Act, 2019, admissibility of the complaint required to be decided within twenty one days of filing of the complaint. The Section 36 (2) of the Consumer Protection Act, 2019 is reproduced as under:-

(2)   On receipt of a complaint made under section 35, the District Commission may, by order, admit the complaint for being proceeded with or reject the same:

 Provided that a complaint shall not be rejected under this section unless an opportunity of being heard has been given to the complainant:

Provided further that the admissibility of the complaint shall ordinarily be decided within twenty-one days from the date on which the complaint was filed.

       

        The prescribed period for admissibility of the complaint is about to expire. Further adjournment for the same purpose would not be justified as it would amounts to wastage of precious time of the Commission.

4.             Furthermore, the claim of the complainant has been repudiated by the OPs, vide repudiation letter dated 14.12.2022, which is reproduced as under:-

“On scrutiny of claim documents, it is observed that as per policy clause 4.1 (j) any expenses for treatment directly arising from or consequent upon any insured person committing or attempting to commit a breach of law with criminal intent. So, as per policy clause 4.1(j) claim is repudiated.

Clause       Description

4.1(i)        Claim Documents.

Any expenses for treatment directly arising from or consequent upon any insured person committing or attempting to commit a breach of law with criminal intent.

5.             To rebut the said repudiation letter, none has put in appearance on behalf of complainant. The position remained same on the adjourned date. It appears that complainant is no more interested to pursue his case.

6.             Thus, in view of the above, the present complaint is hereby dismissed. However, complainant is at liberty to file the fresh complaint before competent court of law, if so desired. Party concerned be communicated of the order accordingly and file be consigned to the record room.

Announced
Dated: 24.04.2023

                                                                 President,

                                                   District Consumer Disputes

                                                   Redressal Commission, Karnal.

 

 

                (Vineet Kaushik)        (Dr. Rekha Chaudhary)                                        

               Member                      Member