DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (CENTRAL)
ISBT KASHMERE GATE DELHI
CC/164/2018
Jitender Rana
S/o Ram Swaroop
R/o 169, Akash Ganga Appt. Pocket-4,
Sector -24, Rohini, Delhi-110085. …..COMPLAINANT
VERSUS
Religare Health Insurance Company Limited,
Having its office at:
1201 & 1202, Vikrant Tower-4,
Rajendra Place, New Delhi-110008 …..OPPOSITE PARTY
Quorum: Ms. Rekha Rani, President
Ms. Manju Bala Sharma, Member
Dr. R.C. Meena, Member
ORDER
Dr. R.C. Meena, Member
Instant complaint has been filed by Sh. Jitender Rana (in short the complainant) under Section 12 of the Consumer Protection Act 1986 (in short the Act) as amended up to date inter-alia pleading therein complainant availed a health insurance policy bearing no. 11585800 from the OP valid from 09/09/2017 to 08/09/2020 for himself as well as his family and paid a premium of Rs. 50,446/-
to the OP. It is further alleged that Complainant’s son, Rahul Rana, suffered severe right knee injury. On assurance of the OP, and on the advice of doctor complainant admitted his son for surgery. Complainant’s son undergone Arthroscopic Right Knee ACL reconstruction with medical meniscus repair and certain laboratory tests were conducted before the above referred surgery. The complainant sought cashless facility from OP but the same was declined. So, complainant himself paid the entire hospital bill and diagnostic charges. Complainant filed the claim with the OP. In response to the e-mails and messages/ sent to OP, OP informed the complainant vide letter dated 04.04.2018 that the claim is in process. Complainant also visited the office of OP to pursue the claim but no satisfactory reply was given to him by the officials of OP. On 18/04/2018 OP sent a letter to Complainant stating that the claim has been declined. Hence the instant complaint was filed seeking direction to OP to pay to the complainant the claimed amount of Rs. 1,53,748/- along with interest @ 24% from 16/03/2018 till realization, Rs. 1,00,000/- for causing mental and physical agony and Rs. 50,000/- as litigation expenses.
Despite service of notice on 26/09/2019, OP chose not to enter appearance hence proceeded ex-parte.
We have heard Sh. Pankaj Gupta, counsel for the complainant and carefully gone through the record. The claim of the complainant has been denied on the ground ‘Permanent Exclusion : hazardous activity, clause 1.29 and 3.10.3./4.2.32. (Annexure K) Complainant has not placed on record the terms and conditions of the policy. During the course of arguments Counsel for Complainant contented that he was not supplied with the terms and condition. As OP has chosen not to enter appearance despite service there is nothing on record to rebut the contentions of the complainant.
OP in its repudiation letter has mentioned permanent exclusion clause : hazardous activity, clause 1.29 and 3.10.3/4.2.32 (Annexure K). The literal meaning of ‘hazardous activity’ is defined as a recreational or occupational activity that is considered highly risky in the context of life or disability insurance. This includes car racing, horse riding, bungee jumping, scuba diving, hang gliding, construction work, and underground mining etc. In order to ascertain as to how the insured got sever right knee injury as alleged by complainant in his complaint we have gone through the discharge summary of the insured Rahul Rana wherein the treating doctor has mentioned ‘‘H/o Right knee injury during football 27 days back, awkward landing heard a pop 1 mm. Keeping in mind the literal meaning of ‘hazardous’ (supra) in our opinion injury received during playing football by a boy of 21 years of age cannot be treated as hazardous activity.
In view of the above discussion, we are of the opinion that OP is liable to pay Rs. 1,53,748/- to the Complainant along with interest @ 9% from the date of institution of the complaint. OP is further directed to pay Rs. 20,000/- as compensation for physical agony and Rs. 10,000/- as litigation expenses. OP shall pay the above said amount to the complainant within 30 days from the date of this order along with interest @ 9% from the date of filing the complaint failing which it shall carry interest @ 9% per annum from the date of the order till its realization. Copy of this order be sent to the parties as statutorily required. File be consigned to record room.
Announced on this 05th of August 2019.
