DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-VII (SW)

[GOVT. OF NATIONAL CAPITAL TERRITORY OF DELHI]

FIRST FLOOR, PANDIT DEEP CHAND SHARMA SHAKAR BHAWAN

CASE NO. CC/500/14

                                                                                                              Date of Institution  : 21.07.2014

                                                                                                                                         Order reserved on  : 17.04.2023

                       Date of Order : 08.05.2023

In the matter of:

Ramesh Kumar

R/o A-10, Main Road,

Begampuri,

Delhi-110086.                                                  ….         Complainant

VERSUS

Oriental Insurance Company Ltd,

2/13-14, Sarai Julena,

New Delhi-110025.                                       ….      Opposite Party

O R D E R

(By  SH. SURESH KUMAR GUPTA, PRESIDENT)

1. The complainant has filed the complaint under Section 12 of Consumer Protection Act (hereinafter referred to as Act) with the allegations that he has been taking Mediclaim policy from the OP for the last 07-08 years.  On 30.08.2013, he has got renewed mediclaim policy which also covers his wife and dependent child for a sum insured of Rs 1,25,000/- and 75,000/- from 30.8.2013 – 29.08.2014.  The names of the persons covered in the policy are shown in the schedule.  He has paid a consideration amount of Rs. 4480/- through accounts payee cheques upon which a computerized policy No. 272100/48/2014/1006 was received without any terms and conditions. On 02.08.2013, his wife got injured due to some fall of weight on her foot.  She was taken to the local doctor who administered stitches and prescribed medicines. The injury did not heal, upon which she was taken to family hospital on 20.09.2013.  The hospital has advised urgent admission where she underwent immediate operation after undergoing various tests. The OP was intimated immediately on admission to the hospital.  The intimation of claim was also sent to the hospital and a confirmation was received by mail. He has forwarded the documents to the OP to settle the claim but in vain. The OP has informed that TPA recommendation has been closed due to late intimation of claim to OP but no closure letter has been received by him till today though a bill of Rs 88,500/- was submitted to OP. The non-settlement of claim shows that there is deficiency of service on the part of OP.  The exclusion clauses are never brought to the notice of beneficiaries.  He has undergone mental agony and harassment due to non-settlement of claim.  Hence, this complaint.

2. The OP has filed the reply with the averments that complaint is no maintainable as there is no deficiency in service. The complainant has not replied to the queries and claim is lying pending.

3. The complainant has renewed Mediclaim insurance policy from 30.08.2013-29-08.2014 and policy was issued.  The copy of the same along with terms and conditions is Annexure R1. On 14.10.2013, the claim was reported by the complainant for the reimbursement of the expenses incurred on the treatment of the wife of the complainant.  It was noticed on the scrutiny of the documents that on 02.08.2013, the injury was suffered by the wife of the complainant and on 20.09.2013 the patient was admitted to the hospital. The intimation was given to the OP after 74 days of the injuries and 24 days after the discharge from the hospital.  The age of the wife of the complainant is reflected as 37 years in the discharge summary and 33 years in the policy.  The OP came to the conclusion from all these facts that claim of the complainant is not maintainable since there was waiting period of 07 days as per condition 4.1 of the Policy for limitation of claim under the policy. The complainant vide separate letter was directed to explain the discrepancies.  The complainant has duly replied vide letter dt 20.1.2014.  The letter was also sent to hospital vide TPA regarding clarification of the age of the patient and hospital has duly replied on 19.11.2013.  The proper reply was not received so claim of the complainant could not be settled till today. Op is not liable to pay a sum of Rs. 85159 with interest along with other damages as claim.  The claim of the compliant is in violation of clause 5.3 of the terms and conditions of the Policy so there is no deficiency in service.

4. The complainant has filed the Rejoinder wherein stand taken in the complaint is reaffirmed and the averments of the written statement are denied.

5. Both the parties are directed to lead the evidence.

6. The complainant has filed his own affidavit in evidence wherein he has repeated the facts as set out in the beginning while briefing the facts.

7. The OP has filed the affidavit of Sh. J. S. Kalsi, Divisional Manager of the OP and reaffirmed the averments of the reply.  The OP has placed reliance upon the documents.

8. We have heard Ld counsels for the parties and pursued the material on record.

9. It is clear from the material on record that complainant has taken a mediclaim policy which covered his wife and dependent child from the OP.  The said policy was valid from 30.08.2013 to 29.08.2014.

10. The wife of the complainant got injured on 02.08.2013.  The treatment was taken from the local doctor but injury did not heal and thereafter she was taken to family hospital on 20.09.2013 where she was operated.  The intimation was given to the OP and even documents were submitted to the OP for the settling the mediclaim.

11. The OP has raised certain queries which were not duly replied by the complainant as per OP.

12. The evidence led by the OP shows that claim of the complainant could not be settled and paid till today as OP has failed to get proper reply from the complainant.

13. All this shows that claim of the complainant has not been repudiated by the OP.  The repudiation of the claim is necessary in order to show that there is deficiency in service on  the part of OP.  The complainant cannot file the complaint if claim has not been repudiated by the OP. The complainant is pre-mature. The reliance is placed upon Revision Petition No 3918/2010 titled as Kamal Singh Vs New India Assurance Company Ltd decided on 14.02.2013 by Hon’ble National Consumer Disputes Redressal Commission, New Delhi (1986-2013 Consumer 17368 (NS) Part 11).

14. The complaint is pre-mature and accordingly same is dismissed.  The direction is hereby given to OP to decide the claim of the complainant on the basis of record within 45 days from the receipt of copy of this Order after giving an opportunity to him to give clarification to the queries, failing which the claim will be decided on the basis of material on record.

• Copy of this Order be supplied to parties free of cost.

• File is consigned to record room thereafter.

• Announced in the open court.