DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi- 110016
Case No.163/15
Shri Arbindo Grover
D-29, Pansheel Enclave
New Delhi-110017. .…Complainant
VERSUS
The New India Assurance Company Limited
R-7A, Green Park Main
New Delhi-110016. ….Opposite Party
Coram:
Ms. Monika A Srivastava, President
Ms. Kiran Kaushal, Member
Sh. U.K. Tyagi, Member
ORDER
Date of Institution:18.06.2015
Date of Order :04.05.2023
Member: Shri U.K.Tyagi
Complainant has made a request for passing an award directing the New India Assurance Company Ltd. (hereinafter referred to as OP) (i) to pay a sum of Rs.33,806/- in settlement along with interest thereon @ 24% per annum; (ii) to pay Rs.50,000/- on account of mental agony, pain etc. and Rs.10,000/- being cost of present litigation.
Brief facts of the complaint are as under:-
The complainant had been taking mediclaim policy from the OP for the sum insured of Rs.175000/- for many years. In 2012, the OP issued policy which covered the complainant and his wife for a revised sum of insurance of Rs.10,00,000/-. And the premium of Rs.26,262/- was paid. The policy was renewed last time for the period 21.10.2012 to 20.10.2013. It was alleged by the complainant that the OP neither provided the terms and conditions of the policy nor any details about the coverage of ailments etc. The complainant was admitted in Max Super Speciality Hospital on 29.09.2013. He was diagnosed with severe vertigo. The intimation about the admission was lodged with OP immediately with the request to authorise the Hospital for the claim of expenses of the complainant. In response, the TPA approved a sum of Rs.37,008/- only as per TPA’s letter dated 01.10.2023. The same is annexed as Annexure C-3.
The complainant submitted the discharge summary, medical bill of Hospital, testing reports in original with OP for released of the medical claim of Rs.72,511/-. The OP release only a sum of Rs.35652/- directly to the Hospital. The OP and TPA had been withholding the rightful claim of the complainant whereas he was insured to the extent of Rs.1,75,000/- as per old policy and Rs.10 Lakhs under the new policy. It is clearcut case of deficiency in service on the part of the OP. Hence the complaint.
OP on the other hand, filed written statement raising interalia preliminary objections. The complaint is liable to be dismissed for violation of conditions of insurance contract which says “warranted that in case the insured has lodged any claim under the previous policy and sum insured is enhanced under the current policy, and sum insured is enhanced under the current policy for a further claim for the same disease during the current policy the earlier limit of sum insured shall be applicable and not the enhanced sum insured”.
It was further contended by the OP that the claim of the complainant is beyond the purview of insurance contract on account of exclusion clause of Insurance Policy. The current claim was paid as per provision of contract under the Policy of insured sum of Rs.1,75,000/- as per recommendation of TPA. The current policy for the period 21.10.2012 to 20.10.2013 for a sum of Rs. 5 Lakhs which was enhanced on 21.10.2012. All the benefits would have been covered after 2 years waiting period. The claim was reported in 2nd year. On the recommendations of TPA, OP released the sum of Rs.38,705/- (35652+3053). The OP also contended that the complainant also filed complaint before Ombudman where vide order dated 08.04.2015, the complaint was dismissed. OP also maintained that the complainant was fully aware of the terms and conditions of the Policy.
Both the parties filed written submissions and evidence in affidavit. Written statement is on record so is rejoinder. Oral arguments were advanced, by the counsel for the complainant and OP’s counsel has not been putting up his presence since many dates. Hence it was considered appropriate to reserve the case for orders being an old case as OP’s arguments are also on record.
This Commission has gone into the entire material placed on record and due consideration was given to the arguments. As stated above, the complainant had got the policy for enhanced insurance for the period under which the complainant got admitted in the Hospital. The OP had only quoted the relevant portion of the policy stating that “The insured had lodged any claim under the previous policy and sum insured is enhanced under the current policy, for further claim for the same disease during the current policy the earlier limit of sum insured shall be applicable and not the enhanced sum insured”.
From the above, this Commission is unable to make out the intent of the policy. It is not under stood why the earlier insured sum shall be applicable whereas the claim had arisen under the currency of this existing policy of enhanced sum of insured i.e. 29.09.2013 to 01.10.2013, the period when he was admitted in Hospital. The complainant had paid premium on the enhanced sum of insurance. The OP, further failed to place the copy of policy under which, the OP had approved the claim and some portion relevant to the OP, is produced in written statement as well as elsewhere i.e. evidence and written submission in their support. It is the duty of the OP or complainant who are in possession of the documents to place the same for the perusal of the Commission for arrival of decision but the OP has not bothered to place the relevant policy under which he is relying to rebut the claim of the complainant.
This Commission has also looked into the claim letter dated 01.10.2013, exhibited at C-3 with the complaint. It is noticed that the deductions on claim of the complainant was made on the earlier insured amount of Rs.17,75,000/-. It is apprehended that claim allowed was restricted keeping in view the lower limit of insured amount. Had the claim considered in enhanced insured of sum, the claim would have been much more. OP has not led any substantive evidence for restricting the claim amount.
In view of above discussion and facts and circumstances in the case, this Commission is convinced that the complainant was entitled for the higher amount of claim. We are of the opinion that the OP is short of obligation which clearly amounts to deficiency in service. Therefore, we direct the OP to pay Rs.30,000/- within two months alongwith interest @ 6% per annum from the date of allowing the less claim i.e. 01.10.2013 from the receipt of this order failing which rate of interest shall be levied @ 7% per annum till its realisation. The other request of compensation and litigation charges are not considered appropriate. Hence these are rejected.
File be consigned to the record room after giving copy of the order to the parties as per rules.
