In the Court of the
Consumer Disputes Redressal Forum, Unit -I, Kolkata,
8B, Nelie Sengupta Sarani, 4th Floor, Kolkata-700087.
CDF/Unit-I/Case No. 62 / 2011.
1) Sri Rajesh Jajodia and Smt. Ranjeeta Jajodia,
85/1, Ballygunge Place, Kolkata-700019. ---------- Complainant
---Versus---
1) The Oriental Insurance Co. Ltd.,
Office at 311100-OIC, DO-I, Middleton Row, Kolkata-700071. ---------- Opposite Party
2) Vipul MedCrop TPA Private Limited,
16/2, Lord Sinha Road, Kolkata-700071. ----------Proforma Opposite Party
Present : Sri Sankar Nath Das, President.
Dr. Subir Kumar Chaudhuri, Member.
Smt. Sharmi Basu, Member
Order No. 17 Dated 29/08/2012.
The petition of complaint has been filed by the complainant Sri Rajesh Jajodia and Smt. Rajeeta Jajodia against the o.ps. The Oriental insurance Co. Ltd. and another. The case of the complainant in short is that complainant no.1 h as a mediclaim under the policy no.311100/48/2010/1367 and renewal policy no.311100/48/2011/2146 being membership no.04FAA0005469C with o.p. no.2. The policy period was from 23.6.10 and the sum assured was Rs.2 lakhs. Complainant no.2 was having a mediclaim policy with o.p. since 2000 and the policy is being renewed from time to time. The mediclaim of the complainant no.2 under the policy no. 311100/48/2010/1367 and renewal policy no.311100/48/2011/2146 being membership no.04FAA0005469C valid from 23.6.09 to 22.6.10 is with o.p. no.2. The policy period of the last policy no. 311100/48/2011/2146 was from 23.6.10 to 22.6.11 and the sum assured was Rs.2 lakhs. Complainant no.2 had undergone Morbid Obesity Sleeve Surgery on 7.5.10 at Apollo Hospital for a period from 6.5.10 to 10.5.10 and thereafter a claim has been filed with o.p. no.1 through a covering dated 11.6.10 enclosing therewith the claim form, photo copies of policy and membership card, original prescription of the doctor and money receipt of the concerned hospital of Rs.25,000/- and hospital bills of Rs.3,31,005/-, all the medicine bills total of Rs.11,471/-, expenses for all reports amounting to Rs.19,870/-, discharge certificate and fitness certificate which was received on 16.6.10 by the office of o.p. no.1. O.ps. did not response to the claim of the complainants and so o.p. no.2 was intimated vide letter dt.23.8.10 with reference to the claim which was submitted with regard to the policy no. 311100/48/2010/1367 with a request for making payment of the claim amount supported by two opinions of the Insurance Ombudsman, Hyderabad and office of The Insurance Ombudsman, Gujrat.
The claim of the complainant was ultimately repudiated on 25.1.11 by o.p. no.1 and the same was informed to o.p. no.2 vide the same letter. The claim of the complainant was repudiated by o.p. no.1 as per Oriental Insurance Policy Clause no.4.19 where there is a permanent exclusion of the “treatment of obesity orf condition arising therefrom (including morbid obesity) and any other weight control programme, services or supplies etc”. Hence the case.
O.p. no.1 had entered its appearance in this case by filing w/v and denied all the material allegations labeled against it and prayed for dismissal of the case. O.p. no.2 did not contest the case by filing w/v and accordingly matter was heard ex parte as against o.p. no.2 and no claim was sought for as against o.p. no.2.
Decision with reasons:
We have gone through the pleadings of the parties, evidence and documents in particular and we find that the repudiation made by o.p. no.1 on the basis of recommendation is not valid since because complainants were not defaulter and they went on making payment of premium in regular manner and the repudiation on the basis of flimsy ground cannot be appreciated and the object of legislature is that a bona fide insured should not be deprived of one’s claim of having insured claim when in particular actual expenses has been incurred by the insured.
In the context of above and on perusal of the entire materials on record minutely we are of the view that the repudiation is not justified and o.p. no.1 had sufficient deficiency being a service provider to its consumers / complainants and complainants are entitled to relief.
Hence, ordered,
That the petition of complaint is allowed on contest with cost against o.p. no.1 and ex parte without cost against o.p. no.2. O.p. no.1 is directed to pay a sum of Rs.2,00,000/- (Rupees two lakhs) only incurred by complainants as medical expenses for the purpose of Morbid Obesity Sleeve Surgery on 7.5.12 at Apollo Hospital and o.p. no.1 is further directed to pay compensation of Rs.20,000/- (Rupees twenty thousand) only for harassment and mental agony and litigation cost of Rs.5000/- (Rupees five thousand) only within 45 days from the date of communication of this order, i.d. an interest @ 9% shall accrue over the entire sum due to the credit of the complainant till full realization.
Supply certified copy of this order to the parties.
