Delhi

West Delhi

CC/14/43

Satish Kumar - Complainant(s)

Versus

Oriental Insurance Company - Opp.Party(s)

23 Apr 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (WEST)

 

CASE NO.  43/2014

SH. SATISHY KUMAR/BIJERNDRI & ORS.(LR’s)

S/o LT. SH. KISHORI LAL,

R/o I-265, KARAM PURA, NEW DELHI-110015                                     …..Complainant

VERSUS

ORIENTAL INSURANCE COMPANY LTD.

AT: 18, 6^TH FLOOR, SHAPURI TIRATH SINGH TOWER,

C-58, JANAKPURI, COMMUNITY CENTRE,

NEW DELHI                                    …..Opposite Party-1

 

O R D E R

 

K.S. MOHI,PRESIDENT

The complainant has filed the present complaint against the O.P under section 12 of Consumer Protection Act, 1986. Briefly stated the facts as alleged by the complainant are that he obtained medi-claim policy No. 215500/48/14/284 for the period from 16/04/2013 to 15/04/2014. The complainant was admitted in MGS Hospital, Rohtak Road, Punjabi Bagh, New Delhi as he was suffering from Jaundice and he was discharged from the Hospital on 07/06/2013 and spent Rs. 45,720/-for his treatment and also spent 10,000/- on other expenses. The complainant sent letter dated 19/06/2013 and 03/07/2013 to OP but of no avail. Thereafter, OP replied letter dated 16.08.2013 by stating that Harnia was since 20 days from the admitted date in Hospital and any disease other than those mentioned in clause 4.3 contacted by insured person during first 30 days from the commencement date of policy except treatment for accidental external injuries was not payable. However, the complainant in the present case took medical claim policy on 16/04/2013 and was admitted in Hospital on 29.05.2013. The OP admitted no deficiency in service is not paying the medical expenses. Hence, the present complaint for refund medi-claim and compensation.

          OP filed reply stating that complaint was not maintainable because complaint has not come to the forum with clean hands. It is further stated that since the policy in question was in the first time w.e.f. 16.04.2013 having issued for one year 16/04/2013 to 15/04/2014 whereas insured was hospitalized on 29.05.2013 with history of cirrhosis of liver disease hypertension and ascitis and the aforesaid illness fell within 30 days from the inception of its first policy. It is further stated that first year policy come under the clause 4.2 of policy terms and conditions. Hence, the claim was not payable. The OP however, admitted the issuance of insurance policy in favour of complainant.

The complainant has filed his affidavit in evidence testifying all the facts as alleged in the complaint on oath.  On the other hand Ms. Meena Kalra, Sr. Divisional Manager has filed affidavit in evidence testifying all the facts as alleged in the written statements on oath and relied upon Ex. OP/A(Colly) .  Parties have also filed their written submissions.

          We have heard Ld. Counsel for the parties and perused the documents carefully and thoroughly.

          Counsel for the complainant argued that OP rejected the claim of the complainant on unjustified grounds and the terms and conditions mentioned in reply of OP are not applicable to the case of the complainant. On the other hand, the counsel for OP Mr. Bhupesh Chandna vehemently stressed that case of the complainant is hit by clause 4.2 and could not be entertained except after expiry of 2 years of the policy period. In support of his submission Mr. Chandna referred to the Hon’ble National Commission Authority reported in 2016 STPL 15645 NC titled New India Assurance Company Ltd. Vs. Rekha Malhotra & Ors. wherein the Hon’ble National Commission observed that claim was not payable by insurance company if covered under the exclusion clause. The facts of this case are quite similar to the case in hand.

          Keeping in view discussion stated above, the claim is dismissed being devoid of any merit.   

          File be consigned to Record Room.

          Copy of Order be given as per rules.

          Announced this_____23TH________ April, 2019.

 

(K. S. MOHI)                                                                            (PUNEET LAMBA)

PRESIDENT                                                                                     MEMBER