Haryana

Sonipat

CC/424/2015

Ram Chander S/o Khazan Singh - Complainant(s)

Versus

The Oriental Insurance Co. Ltd. - Opp.Party(s)

Jitender Singh

01 Jun 2016

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

SONEPAT.

               

                                Complaint No.424 of 2015

                                Instituted on:18.11.2015

                                Date of order:01.06.2016

 

Ram Chander son of Khazan Singh, resident of H.No.156, Vidya Vihar, Pitampura, West Enclave, Delhi.

                                           ...Complainant.

                           Versus

 

Oriental Insurance Co. Ltd., 204-R, Ist Floor, Model Town, Atlas road, Sonepat through its Branch Manager.

                                           ...Respondent.

COMPLAINT UNDER SECTION 12 OF

THE CONSUMER PROTECTION ACT,1986

 

Argued by: Sh. Jitender Singh Adv. for complainant.

           Sh. RP Antil, Adv. for respondent.

    

BEFORE-    NAGENDER SINGH………………………………………………PRESIDENT.

          SMT.PRABHA WATI……………………………………………MEMBER.

O R D E R

            The complainant has filed the present complaint against the respondent alleging therein that he has purchased the medi claim policy for the period 9.2.2015 to 8.2.2016 and unfortunately the wife of the complainant Smt. Krishna Kumari suffered some problem  in her eyes and was admitted in Dr Shroff’s Charity Eye Hopsital, New Delhi in the month of 5/2015 and was operated upon  and the complainant has spent Rs.50,000/- upon the treatment of his wife.  Thereafter the complainant has lodged the claim with the respondent by submitting all the required documents, but the respondent illegally and arbitrarily with held the genuine claim of the complainant and that amounts to a grave deficiency in service on the part of the respondent.  So, he has come to this Forum and has filed the present complaint.

2.        In reply, the respondent has submitted that the complainant has changed the earlier individual policies purchased from the respondent to PNB Oriental Royal Medi Claim policy in the year 2015 from 9.2.2015 to 8.2.2016 securing the complainant and his wife Smt. Krishna Kumari.    The respondent has denied the fact that the complainant has spent Rs.50,000/- upon the treatment of his wife. On Scrutiny of the documents, it was found that the patient namely Smt. Krishna Kumari had history of Cataract surgery and when affected by some person, such a fuchs dystrophy or a trauma during cataract removal, endothelial cells suffers mortality or damage.  The portability was not available for this condition as per clause 4.2 of the terms and conditions of the policy which is reproduced as under:-

          “During the period of insurance cover, the expenses on treatment of cataract for specified period of two years are not payable if contracted and/or manifested during the currency of the policy”. 

          Thus, the claim of the complainant is not liable to be paid under the present policy conditions.   The complainant has not suffered any mental agony, harassment and humiliation at the hands of the respondent and there is no deficiency in service of any kind on the part of the respondent.  Thus, prayed for the dismissal of the present complaint.

3.        We have heard the arguments of both the ld. Counsel for the parties at length and we have also gone through the entire relevant material available on the case file carefully & minutely.

4.        Ld. Counsel for the complainant has argued his case vehemently that the complainant has purchased the medi claim policy for the period 9.2.2015 to 8.2.2016 and unfortunately the wife of the complainant Smt. Krishna Kumari suffered some problem  in her eyes and was admitted in Dr Shroff’s Charity Eye Hopsital, New Delhi in the month of 5/2015 and was operated upon  and the complainant has spent Rs.50,000/- upon the treatment of his wife.  Thereafter the complainant has lodged the claim with the respondent by submitting all the required documents, but the respondent illegally and arbitrarily with held the genuine claim of the complainant and that amounts to a grave deficiency in service on the part of the respondent.

          On the other hand, ld. Counsel for the respondent has submitted that the complainant has changed the earlier individual policies purchased from the respondent to PNB Oriental Royal Medi Claim policy in the year 2015 from 9.2.2015 to 8.2.2016 securing the complainant and his wife Smt. Krishna Kumari.    The respondent has denied the fact that the complainant has spent Rs.50,000/- upon the treatment of his wife. On Scrutiny of the documents, it was found that the patient namely Smt. Krishna Kumari had history of Cataract surgery and when affected by some person, such a fuchs dystrophy or a trauma during cataract removal, endothelial cells suffers mortality or damage.  The portability was not available for this condition as per clause 4.2 of the terms and conditions of the policy which is reproduced as under:-

          “During the period of insurance cover, the expenses on treatment of cataract for specified period of two years are not payable if contracted and/or manifested during the currency of the policy”. 

          Thus, the claim of the complainant is not liable to be paid under the present policy conditions.   The complainant has not suffered any mental agony, harassment and humiliation at the hands of the respondent and there is no deficiency in service of any kind on the part of the respondent.

          In the present case, at the time of arguments, the complainant has placed on record as many as seven policies with effect from 9.2.2008 to 9.2.2015 marked as JN.  The perusal of the above seven policies itself shows that the same were got renewed by the complainant from the respondent time to time without any break.  The perusal of these policies shows that the issuing office name and address is mentioned as Oriental Insurance Co.Ltd., 204-R ModelTown, Atlas road, Sonepat and issuing office code is mentioned as 261600.

          The main difference in the policy which was issued on 9.2.2015 to 8.2.2016 and the previous policies issued w.e.f. 9.2.2008 to 8.2.2015, is regarding policy numbers.  Initially, the policy no.261600/48/2008/1467 was issued w.e.f. 9.2.2008 to 8.2.2009 and insured’s code is mentioned as 17165104 and this code was mentioned in each policies issued w.e.f. 9.2.2014 to 8.2.2015.  But in the policy valid w.e.f. 9.2.2015 to 8.2.2016, the insured’s code is mentioned as 65543573.  Initially the name of the policy was Individual Medi claim Policy Schedule, whereas in the policy valid w.e.f. 9.2.2015 to 8.2.2016, the name of the policy was changed as PNB Oriental Royal Mediclaim Policy Schedule.  This policy was introduced by PNB in collaboration with Oriental Insurance Company for their account holders.

          The perusal of the policies w.e.f. 9.2.2008 to 8.2.2015 shows that in the above said policies, the insured sum was Rs.one lac, which in the policy valid w.e.f. 9.2.2015 to 8.2.2016 was enhanced from Rs.one lac to Rs.five lac.

          Further the perusal of the policies w.e.f. 9.2.2008 to 8.2.2015 and 9.2.2015 to 8.2.2016 shows that in the above policies, the address of the head office is same, the policies are having same code and e-mail ID etc.

          We have perused the exclusion clause as mentioned in the terms and conditions of the insurance policy, which are reproduced below:-

4 Exclusions:

          The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured in connection with or in respect of:

4.1 Pre-existing health condition or disease or ailment/injuries:

          Any ailment/disease/injuries/health condition which are pre-existing (treated/untreated, declared/not declared in the proposal form) in case of any of the insured person of the family, when the cover incepts for the first time, are excluded for such insured person upto three years of this policy being in force continuously.

         For the purpose of applying this condition, the date of inception of the first indemnify based health policy taken shall be considered provided the renewals have been continuous and without any break in period, subject to portability condition.

          This exclusion will also apply to any complications arising from pre-existing ailments/diseases/injuries. Such complications shall be considered as a part of the pre-existing health condition or disease.

4.2       The expenses on treatment of following ailment/diseases/surgeries for the specified periods are not payable if contracted and/or manifested during the currency of the policy.

          If these diseases are pre-existing at the time of proposal the exclusion no.4.1 for pre-existing condition shall be applicable in such cases.

          If the continuity of the renewal is not maintained with the company then subsequent cover shall be treated as fresh policy and clauses 4.1, 4.2 shall apply afresh unless agreed by the company and suitable endorsement passed on the policy.  Similarly, if the sum insured is enhanced subsequent to the inception of the poli9cy, the exclusions 4.1 and 4.2 will apply afresh for the enhanced portion of the sum insured for the purpose of this section.

          So, even after considering the terms and conditions of the policy placed on record by the respondent as Ex.R2, we have come to the conclusion that the complainant is entitled to get his claim amount from the respondent because the complainant continuously and without any break is getting renewal of his policies w.e.f. 9.2.2008 to 8.2.2016.  The first policy was issued by the respondent to the complainant on 9.2.2008 and the policy lastly issued by the respondent is valid and effective for the period 9.2.2015 to 8.2.2016.  The complainant got treated his wife during the validity of the insurance policy and has incurred Rs.50,000/- on her treatment. Thus, the complainant is entitled to get the said amount from the respondent.  Accordingly, we hereby direct the respondent to make the payment of Rs.50,000/- (Rs.fifty thousand) to the complainant within a period of 60 days from the date of passing of this order, failing which, the said amount shall fetch interest at the rate of 09% per annum from the date of passing of this order till its actual realization.

          With these observations, findings and directions, the present complaint stands allowed.

          Certified copy of this order be provided to both the parties free of costs.

File be consigned to the record-room.

 

 

(Prabha Wati)                             (Nagender Singh-President)

Member DCDRF                                  DCDRF, Sonepat.

 

Announced: 01.06.2016