BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BHIWANI.
Complaint No.:88 of 2014.
Date of Institution: 26.03.2014.
Date of Decision:10.04.2017
Subhash Chand son of Sh. Banarshi Dass, resident of village Kanina, Tehsil Kanina, District Mohindergarh.
….Complainant.
Versus
The Oriental Insurance Company Limited, Loharu Road near Bus Stand, Charkhi Dadri, District Bhiwani through its Branch Manager.
...Opposite Party.
COMPLAINT U/S 12 OF CONSUMER PROECTION ACT.
BEFORE: - Shri Rajesh Jindal, President
Mrs. Sudesh, Member
Mr. Parmod Kumar, Member
Present:- Shri Saurabh Goyal, Advocate for complainant.
Shri R.K. Punia, Advocate for OP.
ORDER:-
Rajesh Jindal, President:
The case of the complainant in brief, is that the complainant took the health plan namely “PNB Oriental Royal Mediclaim Policy” of the OP and got himself insured vide policy No. 261204/48/2013/300 for a period of one year i.e. from 08.09.2012 to 07.09.2013 and paid the necessary premium of Rs. 1749/-. It is alleged that the policy of the insurance with its terms and conditions was never served by the OP to the applicant even till today. It is alleged that on 05.01.2013 complainant suffered from Coronary Artery Disease and got himself admitted in the Medanta and remained admitted there and on 07.01.2013 surgery in this regard was done by the concerned surgeon and he was discharged from the hospital on 15.01.2013. It is alleged that a sum of Rs. 2,62,186/- was charged by the above mentioned hospital from the complainant for his treatment and the said amount is covered under the policy. It is alleged that the complainant informed the OP and submitted all the necessary bills and documents to the OP for settlement of the claim but the OP rejected the claim of the complainant. The complainant also got served a legal notice upon the OP. The complainant further alleged that due to the act and conduct of the respondents, she had to suffer mental agony, financial loss and physical agony. Hence, it amounts to deficiency in service on the part of respondents and as such he had to file the present complaint for seeking compensation.
2. On appearance, the OP filed written statement alleging therein that at the time of issuing the policy the agene told all the technicalities of law and its terms and conditions. It is submitted that the complainant did not complete all the formalities and did not reply the letter dated 20.06.2013, 06.07.2013 and final reminder cum closer dated 24.07.2013. It is submitted that the claim case of the complainant has been closed by the competent authority of the company and intimation in this regard has also been served to the complainant. Hence, in view of the facts and circumstances mentioned above, there is no deficiency in service on the part of opposite party and complaint of the complainant is liable to be dismissed with costs.
3. In order to make out his case, the counsel for complainant has tendered into evidence documents Annexure C-1 to Annexure C-10 alongwith supporting affidavit.
4. In reply thereto, the opposite party has tendered into evidence documents Annexure R-1 to Annexure R-6 alongwith supporting affidavit.
5. We have gone through the record of the case carefully and have heard the learned counsels for the parties.
6. Learned counsel for the complainant reiterated the contents of the complaint. He submitted that the complainant has taken the medi-claim policy which was valid from 08.09.2012 to 07.09.2013 for a insured sum of Rs. 1 lakh. He submitted that on 05.01.2013 the complainant suffered from Coronary Artery disease and he was admitted in Medanta Global Health Pvt. Limited, Gurgaon and he had undergone surgery on 07.01.2013 in the said hospital and he was discharged on 15.01.2013. The complainant paid a sum of Rs. 2,62,186/- to the said hospital for his treatment. The complainant lodged the claim with the OP, the OP repudiated the claim of the complainant arbitrarily and illegally.
7. Learned counsel for the OP reiterated the contents of the reply. He submitted that it came to the knowledge of the OP from the documents of treatment that the complainant is a smoker and due to smoking Coronary Artery disease is developed, hence the claim of the complainant is false and the OP rightly repudiated the claim of the complainant vide letter dated 10.08.2013.
8. Indisputably, the complainant taken the treatment for Coronary Artery disease during the currency health policy in question. The OP has repudiated the claim of the complainant on the ground that the complainant is smoker, hence the claim of the complainant is not payable under the terms and conditions of the policy. The proposal form has not been produced by the OP on the file. The counsel for the OP could not bring to our notice the relevant clause to prove that the claim of the complainant is not payable under the terms and conditions of the policy. The complainant was insured for a sum of Rs. 1 lakh and he has incurred treatment expenses of Rs. 2,62,186/-. The complainant cannot claim for more than the sum assured under the policy. Keeping in view the facts and circumstances of the case, we allow the complaint of the complainant and direct the OP to pay Rs. 1 lakh alongwith interest at the rate of 8 per cent per annum from the date of complaint till the date of payment. The OP is directed to comply with this order within 60 days from the date of passing of this order. Certified copies of the order be sent to the parties free of costs. File be consigned to the record room, after due compliance.
Announced in open Forum.
Dated: 10.04.2017.
(Rajesh Jindal)
President,
District Consumer Disputes
Redressal Forum, Bhiwani.
(Sudesh) (Parmod Kumar)
Member Member
