1. The complainant has filed this case against the O.Ps. who wrongly and illegally repudiated the claim of the complainant on the basis of baseless, concocted, false and frivolous observation.
2. The complainant’s case in brief is that the O.P. No. 1 Oriental Insurance Company Ltd. is a body corporate constituted under Company Act to carry out General Insurance business as well as Individual Mediclaim family floater insurance business whole over India through its so many subordinates offices including one at Patna and other at Dumka, i.e; 2 & 3 respectively and O.P. No. 4 is Oriental Bank of Commerce which is a body corporate constituted to carry out its banking business over whole India through its so many subordinates branches/ offices including one at Patna and other at Dumka i.e; O.P. no. 5 & 6 respectively. And not only this, the Oriental Bank of commerce is also corporate agent of Oriental Insurance Company Ltd. and is facilitating the insurance business of Oriental Insurance Co. at its all branch levels including Dumka.
3. Being a corporate agent of O.P. No. 1, O.P. no. 4 through its branches including O.P. 5 & 6 used to promote and sell the Oriental Bank Medi Claim Policy with family floater to its account holder. The complainant being an account holder of O.P. No. 6 in the said proposal form, it has premium amount to o.P. No. 6 in the said proposal form it has been categorically asserted and disclosed that Smt. Kalawati Devi wife of the complainant has Diabetes. The O.P. No.6 in its turn sent the proposal form and premium amount to its another branch to O.P. No. 5 who in its turn sent the said proposal form to its Principal o.P. No. 2 who after considering the said disclosure as mentioned in the proposal for, accepted the proposal of the complainant and issued oriental bank Mediclaim policy with family floater bearing registration policy no. 331100/48/2012/693 in favour of complainant effective from 17.10.12 to 16.01.13 and the said policy was subsequently renewed vide policy no. 331100/48/2013/791 valid and effective from 17.01.13 to 16.01.14 and again it was renewed vide policy no. 331100/48/2014/791 valid and effective from 17.01.14 to 16.01.15.
4. There is no doubt that the said policy was meant to pay hospitalization expenses for medical/ surgical treatment at any nursing home/ hospital in India as in- patient. It is further submitted that during the validity of the policy the complainant got his wife Smt. Kalawati Devi admitted in Dr. Ramchandran’s Diabetes Hospitals, Chennai on 09.11.14 as she was suffering from severe Toe pain, burning sensation in feet and giddiness where she was treated as an in- patient and discharged on 15.11.14 and the complainant paid Rs 48,625 to the said hospital against the medical treatment expenses of Smt. Kalawati Devi.
5. From the day of admission in hospital, the complainant informed the insurer and lodged the claim before the Insurance company which was numbered as 10876252 under 331100/48/2014/751 and also submitted all the requisites papers including the medical treatment bill as required by the Insurance Company vide its e-mail dt. 01.07.15 denied claim of the complainant on some flimsy ground which was not the part and parcel of the complainant of the policy issued to the complainant.  
6. The Insurance Co. wrongly and illegally repudiated the claim of the complainant on the basis of the baseless, concocted, false and frivolous observations which was neither disclosed to the complainant at the time of the policy nor was mentioned in the certificate of policy itself issued by the Insurance Co. The complainant highly protested the said action of the Insurance co. and requested the Insurance Co. to settle the claim failing which the complainant would approach the competent authority of law but till date the O.Ps did not settle the claim of the complainant.
7. The act of the O.Ps is nothing but a patent and glaring deficiency in services rendered by the O.Ps  and it is a patent negligent act of the O.Ps for which the complainant has suffered mental tension, agony, harassment to the tune of Rs 40,000 and due to willful act of deficiency and negligency of the O.Ps the complainant has been deprived of from availing the amount worth Rs 48,625 and the cause of action arose on 09.11.14 and onwards till filing of the case when the claim of the complainant was repudiated.

        8.The complainant claims following reliefs :-

1. To issue and order directing the O.P. 1, 2 and 3 to pay Rs 48,625 on account of incurred medical expenses.
2. Directing the O.P. 1, 2 and 3 to pay Rs 40,000 as compensation on account of mental tension, agony and harassment caused to the complainant due to deficiency and negligency of services of the O.Ps.
3. Directing the O.P. 1, 2 and 3 to pay interest upon Rs 48,625 @ 12% from 15.11.14 till payment.
4. Directing O.P. 1, 2 and 3 to pay cost of litigation of Rs 10,000.        

9. The O.P. No. 1, 2 and 3 i.e; Oriental Insurance Company Ltd. appeared and filed his show cause on 17.10.17 stating therein that the case of the complainant is wholly misconceived, illegal and untenable in law and there is no deficiency in services or latches whatsoever on the part of this answering O.P. This O.P. admitted this fact that the complainant purchased the Oriental Bank Mediclaim Policy family floater bearing policy no. 331100/48/2012/693 in favour of the complainant covering his wife Kalawati Devi and same was effective from 17.01.12 to 16.01.13 and the said policy was renewed for the period from 17.01.13 to 16.01.14 and thereafter and again renewed from 17.01.14 to 16.01.15 and this policy was meant for hospitalization expenses for medical/ surgical treatment at nursing home/ hospital in India as an in-patient. It was further submitted that the complainant informed the insurer that the wife of insured Smt. Kalawati Devi was  admitted in Ramchandran’s diabetic hospital, Chennai  on 09.11.14 for treatment and was discharged on 15.11.14 and the complainant placed his claim for payment before Insurance Co. and the same was repudiated on account of the violation of terms and conditions of mediclaim insurance policy.
10. It was further submitted that as per prescription by Dr. Nauditha Arun it is noticed that the patient was suffering from diabetes mellitus for last 11 years and looking at the policy inception dt. 17.01.12 it was noticed that the history of the stated diagnosis is prior to the policy inception date. Hence, this claim was denied under policy exclusion clause 4.1 of Oriental Bank mediclaim policy since as per this clause of up to 3 years of the policy being in force continuously, claim of the insured cannot be allowed and this 3 years exclusion period in this case was not over till the last date of treatment of the Smt. Kalawati Devi for which claim has been made.                               
11. It is further submitted that the allegation made by the complainant is totally denied that the claim was rejected on flimsy ground and wrongly and illegally repudiated the claim of the complainant. It is further submitted that the time of the inception, the policy purchaser after going through the prospectus of Oriental Bank Mediclaim policy with family floater and having understood the same fills up the proposal form and makes a declaration to this effect and in the said prospectus under the subhead Exclusions, Exclusion clause no. 4.1 pre-existing health conditions or disease or ailment/ injuries. Any ailment/ disease/ injuries/ health condition which the pre existing( treated/ untreated, declared/ undeclared in the proposal form) in case of any of the insured person of the family when the cover incepts for the first time are excluded for such insured person up to 3 years of the policy being in force continuously.

                                         “For the purpose of applying this condition the date of inception of the first indemnity based health policy taken shall be considered, provided the renewals have been continuous and without any break in period, subject to portability condition.” “This application will also apply to any complications arising from pre existing ailments/ disease/ injuries. Such complications shall be considered as a part of the pre existing health condition or disease.” It is further submitted that policy certificate itself has clearly mentioned in the Block capital – for policy details please visit the website, www.orientalinsurance.org.in.

12. In view of terms and conditions of the policy as well as declaration made in proposal form duly accepted by the complainant, the O.P. Oriental Insurance Co. Ltd. is not liable to pay any compensation or any part of compensation and further submitted that in view of the facts and circumstances stated in the show cause the complainant petition deserves to be outright dismissed with cost in favour of the O.P.
13. O.P. 4 to 6 appeared on 01.06.17 and filed his WS – cum – show cause stating therein that the complainant petition is not maintainable against these O.P. No. 4 to 6 either in law or in facts and circumstances of the case and the same is absolutely vexatious, malicious, baseless and frivolous one. The complainant has no cause of action for the aforesaid complaint against this O.P. No. 4 to 6 and no relief whatsoever has been sought from this O.Ps and the same is evident from col. 13 under heading Relief sought of the complainant petition itself.
14. It is further submitted that there is no deficiency or negligency in services as rendered by the Oriental Bank of Commerce nor there is any malafide deceptive trade practice on the part of this O.P. 4 to 6. Admittedly the Oriental Bank of India is a body corporate constituted under Banking services having its one of the branch office at Shree Shyam Plaza, Dumka and is doing it banking business as per the established norms and guidelines of RBI and as because it is a corporate body there is no vested interest of any of its employee against its customer.
15. The present complaint has been filed by the complainant jointly implicating Oriental Bank of Commerce with oriental Insurance Co. without describing their separate role and liabilities though as a matter of fact both are two different business entity having different modus operandi of their respective business and none can be held liable for the business attitude of other. It is further submitted that no doubt Oriental Bank of commerce Dumka Branch has received the insurance premium amount along with the proposal from of the complainant and sent it to Oriental Insurance co. ltd. and accordingly the Insurance Co. has/ had issued the policies in favour of the complainant and admittedly the complainant has received the policies against the premium paid amount.
16. It is further submitted that under the established law of the nation it is the bounden duty of the insurance co. to process and settle all sorts of the insurance claim like the claim of the complainant. It is further submitted that the complainant has not suffered any injury or harassment on account of O.P. 4 to 6 and he has not submitted any evidence in respect of the claim on account of economical loss, reputation loss, mental agony rather all are nothing but a cock and bull story. It is further submitted that there is no any deficiency in services on the part of the answering O.P. nor any negligent act of its employee and the present complaint is fit to be dismissed with cost in favour of the O.P 4 to 6.
17. Apparently from the perusal of complaint petition and the relief column which is no. 13 it appears that the complainant has sought relief only against O.P. 1 to 3 which is Insurance Company and not against the O.P. no. 4 to 6 and also proposal form and transmitted to O.P. 1 to 3 and there is no specific allegation against O.P. 4 to 6 in the complaint petition.
18. The main point for the determination in this case is whether the complainant is entitled to get any relief or reliefs as claimed against O.P 1, 2 & 3 !

                                                                                 Findings

The complainant in support of his case has filed oral and documentary evidence both. He has filed the affidavit of following persons –

  CW1 – Vishnu Kumar

And has also filed the following documentary evidences which are as follows –

Exhibit 1 – photocopy of proposal form of Oriental mediclaim policy

Exhibit 2 – treatment receipt sought

Exhibit 3 – photocopy of Oriental Bank policy scheduled from

1. 17.01.12 to 16.01.13
2. 17.01.13 to 16.01.14 
3. Oriental Bank mediclaim policy scheduled from 17.01.14 to 16.01.15

Exhibit 4 – photocopy reimbursement claim form along with medical expenses receipts. Total 13 sheets.

Exhibit 5 – copy of e-mail which also includes the mail of the O.P. dt. 01.07.15 in which the claim of the claimant was repudiated by the O.Ps

19. The O.P. in support of his case has filed some documentary evidence which are as follows:-

Exhibit A – photocopy of Oriental Mediclaim policy scheduled from 17.01.13 to 16.01.14 and from 17.01.12 to 16.01.13

Exhibit B – proposal form for Oriental Bank mediclaim policy

Exhibit C – prospectus of Oriental Bank mediclaim policy

20. Heard the argument of both the parties in detail and also perused the oral and documentary adduced on behalf of both the parties which is on record and after carefully scrutinizing and analyzing the documents it is admitted fact that no relief was claimed against O.P. 4 to 6 by the complainant as it appears from col. 13 of the complaint petition. As the O.P. 4 to 6 is Oriental Bank and its duty is only as relating to banking business.
21. It is also admitted fact that the complainant got mediclaim policy from Oriental Bank i.e; O.P. No. 1 to 3 and O.P. 1 to 3 clearly admits this fact in his WS in     Para 6 and 7. It is also admitted fact that the policy in question valid from 17.01.12 to 16.01.13 and subsequently renewed from 17.01.13 to 16.01.14 and thereafter it was again renewed from 17.01.14 to 16.01.15 and it is also admitted fact that the wife of the complainant was admitted in Dr. Ramchandran’s diabetic hospital taken on 09.01.14 for treatment and discharged on 15.11.14.
22. From the perusal of Oriental Bank mediclaim policy scheduled i.e; Exhibit 3 corresponding to Exhibit A and also from the perusal of Exhibit 1 corresponding to Exhibit B i.e; proposal form apparently the policies scheduled was granted to the complainant along with his wife after carefully going through proposal form and the proposal form of the complainant clearly discloses this fact that his wife Smt. Kalawati has diabetes. Up to this point there is no difference or controversy or contradiction in this case. The claim of the complainant was repudiated by the O.P. 1 to 3 merely on the ground of exclusion clause which is mentioned in the prospectus i.e; exhibit C as 4.1 which is as follows –

Pre- existing health conditions or disease or ailment/ injuries – Any ailment/ disease/ injuries/ health conditions which are pre – existing (treated/ untreated, declared/ not declared in the proposal form), in case of any of the insured person of the family, when the cover incepts for the first time are excluded for such insured person up to 3 years of this policy being in force continuously.

23. For the purpose of applying this condition, the date of inception of the first indemnity based health policy taken shall be considered, provided the renewals have been continuous and without any break in period, subject to portability conditions. This exclusion will also apply to any complications arising from pre existing ailments/ disease/ injuries. Such complications shall be considered as a apart of the pre existing health conditions or disease.
24.                              On the basis of exclusion clause the O.P No. 1 to 3 denied the claim of the complainant saying that policy certificate itself has clearly mentioned in the Block capital, “for policy details please visit the website, www.orientalinsurance.org.in. It is alleged by the complainant in his complaint petition that Insurance Co. at the time of issuing the Insurance policy not mentioned in the certificate of the policy itself regarding this exclusion claim. He neither disclosed to the complainant nor informed the complainant about this and when he filed his claim form at that time and for the first time he has taken the plea of exclusion clause and on 01.07.15 he denied the claim of the complainant on some flimsy ground which was not part and parcel of the policy issued to the complainant.
25. From going through the policy certificate, i.e; Exhibit 3 there is no whisper regarding the exclusion clause and the complainant at the time of taking the policy in his policy proposal form, i.e; Exhibit 1 has clearly mentioned that his wife Smt. Kalawati Devi has diabetes and knowing this fact the O.P. 1 to 3 has accepted the proposal of the complainant. It was bounden duty of the O.P. when the proposal form was being accepted by the O.Ps he should clearly informed to the complainant regarding the exclusion clause relating to the disease diabetes but O.P. keep mum and he has not reacted or disclosed about the exclusion clause as mentioned in prospectus 4.1 to the complainant before accepting the proposal of the complainant.
26. Not only that they renewed the policy for next consecutive 2 years and when the wife of the complainant was admitted thereafter he filed his claim for medi claim expenses at that time they repudiated the claim of the complainant saying that the case was false under the purview of the exclusion clause and the complainant is not entitled to get any money.  
27. In recent judgment, Hon’ble Supreme Court of India has clearly held that insurers cannot repudiate contract if exclusion clauses are not disclosed to insured as per IRDA Regulations. Here in this case the insurer, i.e; O.P 1 to 3 has not disclosed the insured about the exclusion clause. Up to continuous 3 years they had renewed the medi claim policy consecutively of the complainant. As such the conduct of the O.P 1 to 3 clearly shows his malafide intention not to honor the claim of the complainant. The conduct of the O.P. and repudiation of the claim of the complainant cannot be appreciated in the eye of law or in any way and repudiation of the claim by the O.P. 1 to 3 is apparently illegal, malafide, arbitrary and the O.P. 1 to 3 has not given proper services through act or willful deficiency and negligency in providing services to the complainant.
28. We from the aforesaid discussion hereby,

                                                                                         Ordered

                              That O.P. No. 1, 2 and 3 are directed to pay Rs 48,625/- on account of incurred medical expenses 12% p.a. interest from 15.11.14 till the date of payment. The O.P. No. 1, 2 and 3 are also directed to pay compensation amount of Rs 40,000/- as compensation on account of mental tension, agony, and harassment to the complainant. The O.P. No.1, 2 and 3 are also directed to pay litigation of Rs 10,000/- to the complainant. All the above payment should be made to the complainant by O.P 1, 2 and 3 within one month from the date of this order.

Let a copy of this order be served to both the parties free of cost.

           Let this document be deposited in the record room and also to be shown on the website of the commission.