DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (CENTRAL)
MAHARANA PARTAP BUS TERMINAL: 5th FLOOR.
KASHMERE GATE DELHI.
No. DF / Central/ 2015
Consumer Complaint No | : | CC 40/2009 |
Date of Institution | : | |
| | | |
Manish Goel
S/o Sh. Raghunandan Goel
Resident of WZ 525
Street no. 17 B, Sadh Nagar,
Palam Colony, New Delhi-110045
..........Complainant
Versus
TATA Aig General Insurance Company ltd
Milap Bhawan,
4th Floor, Bahadur Shah Jafar Marg,
New Delhi-110001 ..........Respondent/OP
BEFORE
SH. RAKESH KAPOOR, PRESIDENT
NUPUR CHANDNA, MEMBER
V. K. DABAS, MEMBER
ORDER
Per Sh. RakeshKapoor, President
The complainant had taken a Maharaksha personl injury policy from the OP which was valid for the period 6.9.2007 to 4.9.2008. On 21.1.2008 , the complainant had met with an accident and was operated upon at Jaipur Golden Hospital. He was discharged on 3.7.2008 and had spent a sum of Rs. 51,000/- approximately on the treatment. He had submitted a claim for reimbursement of the above amount but the OP had sent a
Page 1. Order CC 40/2009
cheque for a sum of Rs. 4500./- only. The complainant had protested the against the non-release of the entire amount incurred by him on his treatment but to no result. Hence, the complaint.
The OP has contested the complaint and has filed a written statement. Preliminary objections number 1 and 2 of the written statement are relevant for the purposes of the disposal of this complaint and are reproduced as under:
- The complaint does not disclose any cause of action against the OP hence the complaint may be dismissed with cost. It is submitted that the complainant obtained a MahaRaksha Policy from the OP. At the time of issuance of the policy, the OP clearly explained and supplied the terms and conditions of the policy to the complainant. The OP submits that as per the terms and conditions of the policy, the OP is only entitled to pay daily benefit for every day hospitalization. The daily benefits means as the amount payable for each day spent in the hospital. The daily benefits defined in the policy are as follows:
“Coverage C3
Section : In hospital Indemnity Accident Only
Daily Benefit – means the amount
Page 2. Order CC 40/2009
payable for each day spent in the Hospital.
As per the terms and conditions of the policy, the OP did not cover the medical expenses incurred by the complainant. The OP submits that the complainant was admitted in the hospital for only 3 days and the policy covers only daily benefit defined under the policy for every day of hospitalization upto a maximum of 365 days per injury at Rs. 1500/- per day. The OP paid an amount of Rs. 4500/- towards the liability to the complainant as the complainant was admitted in the hospital for 3 days only. The OP further submits that there was an inordinate delay on the part of the insured in intimating about the claim even still the claim was paid and there is no deficiency on the part of OP. The relevant portion of the terms and condition of the policy with regard to intimation of claim/ loss is reproduced herein.
“ Notice of Claim / Loss- It is a condition precedent to our liability here under that the written notice of claim must be given by you within 7 days after an actual or potential
Page 3. Order CC 40/2009
loss beings as soon as reasonably possible and in any event not later than 30 days after an actual or potential loss begins.”
The alleged accident occurred on 22.1.2008 and the complainant intimated the OP on 12.8.2008 therefore the complainant committed the fundamental breach of the above condition.
The insurance policy alongwith its terms and conditions are annexed as Annexure A. The claim form is annexed as Annexure B.
2.There is no deficiency on the part of the OP therefore the complaint may be dismissed with exemplary cost. It is submitted that as per the policy terms and conditions, the policy did not cover the medical expenses incurred by the complainant during the hospitalization. The policy only covers the daily benefit as defined under the policy for every day of hospitalization upto a maximum of 365 days per injury and the OP has already paid Rs. 4,500/- towards its share of liability under the policy therefore there is no deficiency on the part of the OP.
Page 4. Order CC 40/2009
The OP has contested the complaints on merits but has admitted that it had issued a policy of insurance in favour of the complainant which was subject to its terms and conditions. It has reiterated that it had released to the complainant the amount payable under the terms and conditions of the policy purchased him.
We have heard arguments advanced at the bar and have perused the record.
On behalf of the OP an affidavit has been filed by Sh. Mohd. Azar vasi a Branch Claim Manager who has reiterated the contents of the written statement and has deposed that the amount due under the policy had been released to the complainant. He has deposed that under the terms and conditions of the policy purchased by the complainant he was entitled to the reimbursement of the room charges at the rate of Rs. 1500/- per day. He has deposed that since the complainant had remained admitted in the hospital for 3 days a sum of Rs. 4500/- was released to him as the amount due. There is no rebuttal to the above evidence. We are convinced that the OP had acted in accordance with the terms and conditions of the policy purchased by the complainant and the amount due had already been released to him vide a cheque. We, therefore, see no merits in this complaint. The same is hereby dismissed.
Copy of the order be made available to the parties as per rule.
File be consigned to record room.
Announced in open sitting of the Forum on.....................
(NUPUR CHANDNA) (DR.V.K.DABAS) (RAKESH KAPOOR)
MEMBER MEMBER PRESIDENT
Page 5. Order CC 40/2009
