THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR

Consumer Complaint No. 634 of 2014

Date of Institution : 3.12.2014

Date of Decision : 13.08.2015

Yash Paul Bhatia son of Sh. Charan Dass Bhatia, resident of 45-A, Rani Ka Bagh, Amritsar

...Complainant

Vs.

The Oriental Insurance Company Limited Divisional Office-I, Dwarkadheesh Complex, Queens Road, Amritsar through its Senior Divisional Manager/Branch Manager/Person Over All Incharge

....Opp.party

Complaint under section 12/13 of the Consumer Protection Act, 1986

Present : For the complainant : Sh. Deepinder Singh,Advocate

For the opposite party : Sh. Sandeep Khanna,Advocate

Quorum : Sh. Bhupinder Singh, President ,Ms. Kulwant Bajwa,Member &

Sh.Anoop Sharma,Member

Order dictated by :-

Bhupinder Singh, President

-2-

1. Present complaint has been filed by Yash Paul Bhatia under the provisions of the Consumer Protection Act alleging therein that he obtained cashless policy namely Overseas Mediclaim Business and Holiday Policy Schedule bearing No. 233300/48/2015/897 with insured code of the complainant as 61309297 for the period of 60 days i.e. from 24.5.2014 to 22.7.2014. According to the complainant opposite party supplied only insurance cover note but never supplied the original policy as well as terms and conditions of the impugned insurance to the complainant. During holiday , complainant went to Austria, Paris, Switzerland etc., and the complainant started his journey on 8.6.2014 to 9.7.2014. During this period the complainant became ill and hospitalized on doctors advice and he applied for cashless insurance claim . But the said claim was not cleared at that time . Thereafter complainant came back to India . The complainant was surprised that the opposite party did not settle the claim despite fulfilling all the requisite formalities. Thereafter complainant served a legal notice dated 22.8.2014 with the request to pay the claim amount but to no avail. Alleging the same to be deficiency in service complaint was filed seeking directions to the opposite party to pay the sum insured amount to the tune of Euro 3160 i.e. Rs. 2,84,400/- alongwith interest @ 18% p.a. Compensation of Rs. 50000/- alongwith litigation expenses were also demanded.

2. On notice opposite party appeared and filed written version in which it was submitted that complainant obtained the aforesaid policy from the opposite party as Per General Condition 1(i) of the aforesaid Overseas Mediclaim Policy, the policy will be valid only if the insured journey commences within 14 days of the first day of Insurance. It was submitted that as the complainant did not start his journey within 14 days from the first day of insurance, so there is violation of the terms and conditions of the policy on the part of the complainant, as such the amount is not payable by the opposite party. It was submitted that opposite party repudiated the claim of the complainant since the complainant did not comply with the basic mandatory , as such there is no deficiency of service on the part of the opposite party qua the complainant.

3. Complainant tendered into evidence his affidavit Ex.C-1 alongwith documents Ex.C-2 to Ex.C-12.

4. Opposite party tendered into evidence copy of terms and conditions of Overseas Mediclaim Policy Ex.OP1, copy of policy schedule Ex.OP2, copy of e-mail Ex.OP3, affidavit of Sh. Gurdeep Singh , Branch Manager Ex.OP4.

5. We have carefully gone through the pleadings of the parties, arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by the parties with the valuable assistance of the ld.counsel for the parties.

6. From the record i.e.pleadings of the parties and the evidence produced on record by the parties, it is clear that complainant obtained cashless policy namely Overseas Mediclaim Business and Holiday Policy Schedule bearing No. 233300/48/2015/897 Ex.C-8 with insured code of the complainant as 61309297 for the period of 60 days i.e. from 24.5.2014 to 22.7.2014. Opposite party supplied only insurance cover note Ex.C-8 to the complainant and they never supplied the original policy as well as terms and conditions of the impugned insurance to the complainant. The complainant went to Austria, Paris, Switzerland etc., and the complainant started his journey on 8.6.2014 upto 9.7.2014. During this period the complainant became ill and he was hospitalized from 5.7.2014 to 9.7.2014 as per discharge card dated 9.7.2014 Ex.C-11 and the complainant had to spend Euro 3160 as per bill dated 9.7.2014 Ex.C-15. The complainant applied for cashless insurance claim , but the same was not provided. Then the complainant lodged claim with the opposite party after discharge from the hospital. But the opposite party did not settle the claim of the

complainant. Then the complainant served legal notice dated 19.9.2014 Ex.C-4 upon the opposite party. Then opposite party repudiated the claim of the complainant vide letter dated 14.10.2014 Ex.C-9 on the ground that as per terms and conditions of the policy, the complainant/insured had to travel within the first 14 days of the policy. As such ,the claim is not payable. Ld.counsel for the complainant submitted that the complainant was never supplied terms and conditions of the policy nor the complainant was told this condition of travelling within 14 days from the date of issuance of the policy, whereas the policy of the complainant is valid from 24.5.2014 to 22.7.2014, as is evident from the policy Ex.C-8. Therefore, the opposite party has wrongly repudiated the claim of the complainant and all this amounts to deficiency of service on the part of the opposite party qua the complainant.

7. Whereas the case of the opposite party is that no doubt the complainant obtained the aforesaid policy from the opposite party as per General Condition 1(i) of the aforesaid Overseas Mediclaim Policy, the policy will be valid only if the insured journey commences within 14 days of the first day of Insurance. But the complainant did not start his journey within 14 days from the first day of insurance. So there is violation of the terms and conditions of the policy on the part of the complainant. As such the amount is not payable by the opposite party. Ld.counsel for the opposite party submitted that opposite party has rightly repudiated the claim of the complainant vide letter Ex.C-9, as such there is no deficiency of service on the part of the opposite party qua the complainant.

8. From the entire above discussion, we have come to the conclusion that complainant obtained policy namely Overseas Mediclaim Business and Holiday Policy Ex.C-8 from the opposite party for the period from 24.5.2014 to 22.7.2014. The complainant has categorically deposed in his affidavit Ex.C-1 that the opposite party supplied only Insurance cover note Ex.C-8 and they never supplied original policy as well as terms and conditions of the insurance policy to the complainant and this fact has not been rebutted by the opposite party. The complainant went to European tour from 8.6.2014 to 9.7.2014 and during this period complainant became ill and he remained admitted in the hospital from 5.7.2014 to 9.7.2014 as per the treatment card Ex.C-14 and he spent 3160 Euro as per bill Ex.C-15. Policy was cashless policy. But even the opposite party did not give the cashless facility to the complainant. After discharge from the hospital, complainant lodged claim with the opposite party. But the opposite party repudiated the claim of the complainant vide letter dated 14.10.2014 Ex.C-9 on the ground that as per terms and conditions of the policy, it is necessary for the insured to travel within 14 days of the date of policy,so that policy is considered valid. So the opposite party refused to pay the claim to the complainant.

It stands fully proved on record that complainant was supplied only cover note of the policy which is Ex.C-8 in which it has been categorically mentioned that the period of insurance policy is from 24.5.2014 to midnight of 22.7.2014 . Nowhere on this cover note which runs into four pages, it has been mentioned that the policy shall be considered valid only if the insured travels within first 14 days of the policy. Whereas it has been clearly mentioned on this cover note that the policy is fully valid for the period from 24.5.2014 to 22.7.2014. The terms and conditions of the policy were never supplied to the complainant. It has been held by the Hon'ble National Commission in case The Oriental Insurance Co.Ltd. Vs. Satpal Singh & Others 2014(2) CLT 305 that onus to prove that the terms and conditions were supplied to the insured is on the Insurance company. But in this case the opposite party could not produce any evidence to prove that the terms and conditions of the Insurance policy in question were supplied to the complainant. It has further been held by the Hon'ble Supreme Court of India in case M/s. Modern Insulators Ltd. Vs. Oriental Insurance Co.Ltd 2000(1) CPC 596 that where the terms and conditions of the policy were not supplied to the insured, the same are not binding on the insured. The complainant went on European tour from 8.6.2014 to 9.7.2014 during the period of policy he fell ill and was hospitalized during validity of the insurance policy from 24.5.2014 to 22.7.2014. So the opposite party was not justified in repudiating the claim of the complainant on this ground that he did not travel on tour within first 14 days from the date of commencement of the policy.

9. Resultantly we hold that opposite party has wrongly repudiated the claim of the complainant. Hence, the complaint is allowed with costs and the opposite party is directed to reimburse the amount of 3160 Euro or equivalent to Indian currency at the rate prevalent on the date of payment , to the complainant, within one month from the date of receipt of copy of order ; failing which opposite party shall be liable to pay interest @ 9% p.a on the amount of 3160 Euro or equivalent to Indian currency , from the date of filing of complaint till payment is made to the complainant. Opposite party is also directed to pay litigation expenses Rs. 2000/- to the complainant. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

13.08.2015 ( Bhupinder Singh )

President

( Kulwant Kaur Bajwa) (Anoop Sharma)

/R/ Member Member