Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 222.
Instituted on : 22.05.2018.
Decided on : 08.06.2021.
Azad Singh age 46 years, s/o Sh. Lajpat Singh R/o H.No.920, Sector-3, Rohtak, District Rohtak.
………..Complainant.
Vs.
- The Senior Divisional Manager, The Oriental Insurance Company Ltd., Jawahar Market, D.Park, Model Town. Rohtak-124001.
- The Regional Manager, The Oriental Insurance Company Ltd., Oriental House, P.B. No.7037, A-25/27m Asaf Ali Road, New Delhi-110002.
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
MS. TRIPTI PANNU, MEMBER.
Argued: Sh.Rajesh Goyat , Advocate for the complainant.
Sh.R.K.Bhardwaj, Advocate for opposite parties.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case are that complainant had taken a health policy bearing no.261200/48/2016/1776 on 10.12.2015 to 09.12.2016. During the period of policy, the complainant got Acute Gastro Enteritis and the complainant was medico legally examined and treated at Chhotu Ram Hospital and he spent an amount of Rs.84100/- on his treatment. The complainant has filed the claim with the opposite party but the opposite party has illegally repudiated the claim of the complainant vide its letter dated 17.12.2016. Complainant requested the opposite party to make the payment of genuine claim of the complainant but any heed was not paid to his requests. The act of opposite parties is illegal and amounts to deficiency in service. Hence this complaint and it is prayed that opposite parties may kindly be directed to make the payment of Rs.84100/- alongwith interest, compensation and litigation expenses to the complainant as explained in relief clause.
2. After registration of complaint, notice was issued to the opposite party. Opposite party filed its written statement on 14.11.2018 and also filed the amended written statement on 01.03.2021. As per amended written reply opposite party has submitted that according to the medical record of the complainant, the complainant was suffering from obstructive sleep apnoea, acute gastro enteritis under sleep study and claimant is managed by CPAP and discharged on dated 05.06.2016. Claimant is covered under PNB Oriental Royal Mediclaim Policy since 10.12.2014. As per policy, expenses of equipment used for diagnosis and treatment of obstructive sleep apnoea are not admissible. Hence the claim stands repudiated under the policy exclusion 4.15”. Thus there is a violation of terms and condition No.4.15 of the policy and the claim is not payable. All the other contents of the complaint were stated to be wrong and denied and opposite party prayed for dismissal of complaint with costs.
3. Ld. Counsel for the complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C29 and has closed his evidence on dated 11.09.2019. On the other hand, ld. counsel for the opposite party has tendered affidavit Ex.RW1/A, documents Ex.R1 to Ex.R6 and has closed his evidence on dated 02.11.2020.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. In the present case it is not disputed that the complainant has got treatment for his ailment during the policy period and had spent an amount of Rs.84100/- but the claim of the complainant has been repudiated by the opposite party on the ground that the complainant was suffering from obstructive sleep apnoea, acute gastro enteritis under sleep study. As per policy, expenses of equipment used for diagnosis and treatment of obstructive sleep apnoea are not admissible. Hence the claim stands repudiated under the policy exclusion 4.15”. But in the present case, opposite party has not placed on record any document to prove that the such exclusion clause no.4.15 was part of the policy. Even the terms and conditions of the policy (PNB-Oriental Royal Mediclaim Policy-2017) have been placed on file at the time of arguments. It has not been placed on record that on which date the detailed terms and conditions (PNB-Oriental Royal Mediclaim Policy-2014) have been supplied to the complainant by the respondent officials. Merely a cover note/policy schedule has been supplied to the complainant, which is not annexed with the terms and conditions of the policy. No detailed policy has been supplied to the complainant. Hence the repudiation of claim on the ground of exclusion clause no.4.15 of the policy is illegal and amounts to deficiency in service. As such, complainant is entitled for the claim amount as spent by him on his treatment amounting to Rs.84100/- and to prove the same, copy of bills Ex.C4 to Ex.C20 have been placed on record.
6. In view of the facts and circumstances of the case we hereby allow the complaint and direct the opposite party to pay the amount of Rs.84100/-(Rupees eighty four thousand one hundred only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e.22.05.2018 till its realization and shall also pay a sum of Rs.5000/-(Rupees five thousand only) as compensation on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.
7. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
08.06.2021.
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Nagender Singh Kadian, President
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Tripti Pannu, Member.
