Delhi

North

CC/231/2018

ABHISHEK CHAUHAN - Complainant(s)

Versus

ORIENTAL INSURANCE COMPANY LTD. - Opp.Party(s)

K.S. RANA

23 Aug 2023

ORDER

District Consumer Disputes Redressal Commission-I (North District)

[Govt. of NCT of Delhi]

Ground Floor, Court Annexe -2 Building, Tis Hazari Court Complex, Delhi- 110054

 

Consumer Complaint No.:231/2018

 

Sh. Abhishek Chauhan

S/o Sh. Pradeep Chauhan,

1140, Gali No.12, B-Block,

Baba Colony, Burari,

New Delhi-110084                                                                                  …                      Complainant No.1

 

Sh. Pradeep Chauhan

S/o Sh. Bharat Singh Chauhan,

1140, Gali No.12, B-Block,

Baba Colony, Burari,

New Delhi-110084.                                                                                …                       Complainant No.2

 

                                                                        Vs

 

M/s Oriental Insurance Co. Ltd.

Oriental House,

Punjab National Bank,

A-9, Connaught Place,

New Delhi-110001.

 

Also at:

M/s Oriental Insurance Co. Ltd.

88, Janpath, Ground Floor,

New Delhi.                                                                                            …                          Opposite Party

ORDER

23/08/2023

 

Ashwani Kumar Mehta, Member:

 

1.         The present complaint has been filed under Section 12 of the Consumer Protection Act, 1986. The brief details of facts, as alleged by the Complainants in the Complaint in hand, are that the Complainants were the policy holder of PNB-Oriental Royal Mediclaim Insurance Policy No.272900/48/2016/28409 having validity from 30.03.2016 to 29.03.2017. At around 07:00 PM on 16.07.2016, Complainant No.1 was hit by an unknown vehicle and being injured, was admitted in Babu Jagjiwan Ram Memorial Hospital, Delhi-110033 vide MLC No.118511. Thereafter, for better treatment, Complainant No.1 was admitted in the Fortis Hospital, A-Block, Shalimar Bagh, Delhi-110088 on 20.07.2016 where his Surgery and other treatment was done. The treatment record has been filed with complaint as Ex.CW-1/2. The Fortis Hospital, on discharge of complainant no.1, raised a bill of Rs.1,50,988/- which was paid by Complainant No.2. The Complainant filed claim with OP insurance company  seeking reimbursement of the above said amount vide  I.D. No.13010435 on 16.07.2016 but the Opposite Party repudiated the claim vide letter dated 12^th December, 2016 explaining the reasons of repudiation with the following wording:-

“As per FIR, patient having smell of alcohol consumption, hence denied under clause 4.7”

 

2.        It has been alleged by the complainants that the act of OP for rejection of the reimbursement claim, amounts to deficiency in service for which the OP is liable. Therefore, the complainant has filed this Complainant praying for directions to OP to reimburse claim amount of Rs.1,50,998/- and pay Rs.50,000/- as compensation amount for suffering caused by the OP due to deficiency in service and Rs.11,000/- as cost of legal notice.

 

3.         Accordingly, notice was issued to the OP and in response, the OP has filed its reply stating that the complaint is not maintainable and liable to be dismissed as there is not deficiency of services on the part of the OP. The aforesaid complaint so made by the Complainant under the explained circumstances is not tenable as per the law. It is further contended by the OP that the Complainant No.1 was treated by the Hospital concerned for the injuries sustained in an accident due to own act & conduct being alcoholic [as per FIR & MLC], and as per policy wordings, the claim of the Complainant was found not payable under the exclusion clause 4.7”. Therefore, the claim filed by the complainants was rightly repudiated vide repudiation letter dtd. 12.12.2016”.  The provisions mentioned in Exclusion Clause No.4.7, of the policy are reproduced below:-

“All psychiatric and psychosomatic disorders and diseases/ accident due to and use, misuse or abuse of drugs/alcohol or alcohol or use of intoxicating substances or such abuse or addiction etc”

 

4.        As such, the complaint has been examined in view of the facts of the case and averments/documents/Evidence put forth by the complainant & OP. and it has been observed that during the proceedings on    , the Complainant has submitted a copy of Closure Report filed before the court of MM-09 on 31.05.2022 and on perusal of this closure report , it has been found that Under Part-VIII of closure report ( Heading: Apparent contributing circumstances) at item (I) relating to column “under influence of liquor or drugs. Give quantity/ parameters/ recovery, if available”, entry has been made as “N/A” which is sufficient to corroborate that the Complainant No. 1 was not under the influence of liquor/alcohol at the time of accident and the repudiation of the claim by OP was unjustified which amounts to deficiency of service.

5.         In view of the above observations, we are of the considered view that the complainant has suffered directly due to deficient service of the OP (M/s Oriental Insurance Co. Ltd.) in terms of the deficiency defined in the Act which includes  any fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance which is required to be maintained in relation to any service and includes any act of negligence or omission or commission by such person which causes loss or injury to the consumer.

6.        Therefore, we feel appropriate to direct the OP (M/s. Oriental Insurance Co. Ltd.) to pay Rs.1,50,988/- (Rupees One Lakh fifty Thousand Nine Hundred Eighty Eight only) within thirty (30) days from the date of this order, with interest at the rate of 9% p.a. from 12-12-2016  (date of repudiation of claim) till the date of the payment. Besides, the OP is also directed to pay Rs.25000/-   (Rupees Twenty five Thousand only) as compensation to the Complainant, for the mental pain, agony and harassment. It is clarified that if the abovesaid amount is not paid by the OP to the Complainant within the period as directed above, the OP shall be liable to pay interest @12% per annum from the date of expiry of 30 days period.

7.         Order be given dasti to the parties in accordance with rules. Order be also uploaded on the website. Thereafter, file be consigned to the record room.

 

ASHWANI KUMAR MEHTA                                            DIVYA JYOTI JAIPURIAR

              Member                                                                                    President       

     DCDRC-1 (North)                                                                     DCDRC-1 (North)