Per M.P.KASAR Member

1. Complainant states that, he is the legal heir and next of kin to Mrs.Malti Prabodh Shah, deceased on 11/10/2018.  It is stated that, the deceased  had purchased the EXPLORE –ASIA Travel Health Insurance Policy for the benefit of herself and her husband Mr.Prabodh  from the opposite party No.1 on 22/04/2016 by paying the premium of Rs.5346/- for her travel to Singapore for the period 50 days i.e.29/04/2016 to 17/06/2016 client ID was 53441748 and policy No.10601802, complainant is nominated as the nominee by mother i.e. Malti Prabodh Shah.Late Malti suffered a fracture in the left hip due to accidental fall on 18/05/2016 so admitted in Hospital at Singapore  on 18/05/2016 and discharged on 22/05/2016.  Complainant lodged the claim under the benefit of Inpatient care on 18/05/2016 and opposite party No. Sent their requisite forms so complainant vide his letter dated 14/06/2016 extended the policy No.10601802 from 17/06/2016 till 31/08/2016 by stating that the insured person had undergone a surgery. Claim forms were submitted on 04/07/2016 at the office of opposite party No.2 as per instruction of opposite party No.1.total claim under the claim form was amounting to Rs.1596575/- towards the said surgery. But vide letter dated 18/07/2016 opposite party No.1 rejected the entire claim of the complainant by stating the reason of non disclosure of pre exiting medical condition as per clause 5.1.  It is stated that, vide letter dated 01/11/2017 complainant had addressed the said issue to insurance ombudsman by stating the facts and circumstances leading to the claim under the Travel Insurance Policy. There is no reply from the opposite parties as well as ombudsman according to the complainant. The delay caused is due to according to the complainant is there is no response from the insurance ombudsman as per letter sent on 03/11/2017
2. Opposite parties appeared and filed their say stating in that, opposite parties opposes the fact that condonation of delay filed by the complainant has not been explained in a proper manner. According to the opposite parties complaint shall not admit unless it is filed within 2 years from the date on which the cause of action has arisen. It is stated that, letter was addressed by the mother of the complainant in the year 2017 whereas she had expired in the year 2018 so according to the opposite parties even if the insurance ombudsman would have replied, the original complainant i.e. the mother of the applicant would not have been there to attend the office of Insurance Ombudsman as she had already demised. Thus according to the opposite parties the delay are unconvincing and it is crystal clear that the complainant is lying on the face of this forum and making false & frivolous statements so as to make the illegal claim absolute.   So delay of so many cannot be condoned. Dismissed application with cost.
3. Heard Adv.Ankita Sowain for complainant and Adv.Nidhi Bangera for opposite parties on 3/8/22.Perused application and say filed by the opposite parties and documents annexed along with complaint in regard claim. To decide application on merit below section 24A of Consumer Protection Act 1986  and in order to that, we framed issues as follows :-

ISSUES

Findings:-

As to issue No.1 & 2 :-      From the perusal of written say of opposite party nowhere they have mentioned in regard when did claim made by complainant repudiate by them.  But we noted  from the application that, the opposite party No.1 vide their letter 18/07/2016 under the caption Claim Rejection letter  the entire claim of the complainant by stating the reason of NON-DISCLOSURE OF PRE-EXISTING MEDICAL CONDITION as par clauses 5.1 0f the policy terms and conditions. Said letter is at Exh-B of the complainant.  

It is noted that, complainant /applicant vide its letter dated 03/11/2017 had addressed the said issue to insurance ombudsman which is at Exh-C of the complaint but according to the complainant there is no any reply.

No dispute observed from the perusal of written say of opposite parties in regard said policy issued by opposite party No.1 to the complainant. Allegations of complainant in complaint are pertaining to wrongly repudiation of claim of complainant by the opposite parties & pending subject matter before ombudsman. Opposite parties herein also failed to produce any information in regard letter which had addressed by the complainant to ombudsman it is because in their written say opposite parties has uttered that, ‘even if the Insurance ombudsman would have replied, the original complainant i.e. mother of the applicant would not have been there to attend the office of Insurance ombudsman as she had already demised.’

We have noted from the complaint that, original complainant died on 11/10/2018.It is noted that, there is no any reply from the ombudsman office to the complainant or complainant’s mother i.e. deceased so it can be held that, subject matter in regard of repudiation of claim by opposite parties vide dated 18/07/2016 is pending till filing of the present complaint before ombudsman. It is not contention of opposite parties that after repudiation of claim complainant approached to ombudsman belatedly. So we are of the opinion that, subject matter of repudiation being pending before ombudsmanform the date 03/11/2017 onward and original complainant i.e. complainants mother Malti died on 11/10/2018 if according to complainant there is delay of 554 days can be condoned in view of  judgement passed by Hon’ble State Commission in First Appeal No.FA 15/623 vide dated 03/04/2018  in the matter of Smt.Kamalavati Suryakant Rane v/s National Insurance Company and otrs  in which Hon’ble State Commission has held that, ‘Considering issues related to insurance claim not get to complainant below said admitted policy issued in the year 2005-2006  and issues raised by the opposite party can be decide on merit’

So in instant case issues raised by complainant in regard repudiation of complainants said claim can be decided on merit.So in view of issue No.2 we pass order as follows:-

ORDER

Misc.Application No.20/20 in CC/20/31 for delay condonation filed by the complainant is hereby allowed below section 24 (2) of Consumer Protection Act 2019 and delayOF 554 days is hereby condoned in the interest of justice and no order as to cost.