Delhi

West Delhi

CC/13/100

ANIL KUMAR - Complainant(s)

Versus

ORIENTAL INSURANCE - Opp.Party(s)

27 Mar 2019

ORDER

          DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (WEST)

 

CASE NO.  100/2013

SH. ANIL KUMAR S/o SH. JANARDHAN DAS

ADD- A-59, ASHOK VIHAR,

PHASE-II,

NEW DELHI-110052.                                                                        …..Complainant

VERSUS

THE ORIENTAL INSURANCE COMPANY LTD.

DIVISIONAL OFFICE: 26 (CODE NO. 272600),

19-A, SARTI COMPLEX (OPP. DUSSEHRA GROUND),

JWALA-HERI-MARKET, PASCHIM VIHAR,

NEW DELHI-110063…..Opposite Party-1

 

THE ORIENTAL INSURANCE COMPANY LTD.

GRIEVANCE CELL, A-25/27,

ASAF ALI ROAD,

NEW DELHI – 110002. …..Opposition Party-2

O R D E R

 

 

K.S. MOHI,PRESIDENT

The complainant filed the present complaint on the averments that he had taken a medical claim policy in which his wife Ms. Usha was also insured by policy no. 272600/48/2012/517. The wife of the complainant was admitted in Pentamed Hospital for treatment and incurred medical expenses of Rs. 79.671/-. Subsequently, the wife of complainant received letter dated. 10.04.2012 from OP regarding submission of the policy and they have also requested to provide all previous policies prior to 05.05.2011 and accordingly the complainant supplied all the previous policies commencing from the order 2008. The complainant filed claim for the medical expenses which was repudiated by the OP on the ground the complainant had pertained pre-existing diseases. Hence, it was not payable. Since the repudiation was unjustified so complainant filed the present complaint.

          OP filed reply taking preliminary objection and inter-alia that the policy in question was retained from M/s Sputnik Medical & Research Foundation by misrepresentation/concealment of facts and that M/s. Sputnik Medical & Research Foundation medical being necessary party has not been made a party in the present case. On merits, it has been stated that the claim was rejected by third party administrator (TPA) against treatment of “DUB with fibroids uterus with endocervical polyp” which communicated that they were not revealed that of their pre-existing diseases which were not payable as per exclusion clause no. 4.3 of the provisions of Happy Family Floater Policy. The disease suffered by complainant was not payable within the period of two years of inception of the policy under exclusion clause no. 4.3. Therefore, the complaint deserves dismissal.

The complainant has filed his affidavit in evidence testifying all the facts as alleged in the complaint.  On the other hand Sh. R.S. Kalra has filed affidavit in evidence testifying all the facts as alleged in the written statements.  Parties have also filed their written submissions.

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

The controversy involved in the present case is as to whether the complainant is entitled to relief sought or not. The counsel for complainant has vehemently stressed that he has been taking the policy from the OPs since 2008 and he suffered the disease in May 2011 and therefore the cap of two years of exclusion clause 4.3 was already over and he was entitled to the claim. Counsel for OP relied upon authority reported in 2016 S.T. PL 1465(NC) case title New India Ass. Co. Ltd. Vs. Rekha Malhotra and Ors. wherein it was held that repudiation of death claim on ground of suppression of pre-existing disease of diabetic mellitus and hypertension was held to be covered by exclusion clause. Hence, not payable.

          The aforesaid authority in our view does not apply to the facts of the present case because the claim in question was reputed on the ground that 2 years have yet not passed since inception of the policy whereas the complainant has filed on record, the series of previous policies by the same insurance company without any gap and, therefore, the embargo of two years was not attracted in the present case. Even, otherwise it is not a case of death wherein pre-existing disease was concealed by the insured. We may also clarify here that even the terms and conditions including the exclusion clause were not supplied to the complainant at the time of commencement of policy.

          Keeping in view above circumstances and observations we award a sum of Rs. 71,885/- with interest @ 6% from the date of filing complaint till actual realization in favour of complainant against OPs and further award a sum of Rs. 10,000/- towards mental, agony and physical harassment and litigation expenses to be paid within 45 days from the receipt of the order. In case of default of payment in time OPs shall be liable to pay interest @ 6% p.a. from the date of filing of the complaint till actual realization.

File be consigned to Record Room.

          Copy of Order be given as per rules.

          Announced this _____27TH______March, 2019.

 

(K.S. MOHI)                                                                              (PUNEET LAMBA)

PRESIDENT                                                                                         MEMBER