Haryana

Sonipat

CC/429/2015

Sahab Singh S/o Hawa Singh - Complainant(s)

Versus

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

Jitender Singh

23 May 2016

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

SONEPAT.

               

                                Complaint No.429 of 2015

                                Instituted on:23.11.2015

                                Date of order:23.05.2016

 

Sahab Singh son of Hawa Singh, resident of village Nara, tehsil Madlauda, distt. Panipat.

                                           ...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  a PNB Oriental Royal Mediclaim policy for health insurance from the respondent valid w.e.f. 9.8.2014 to 8.8.2015 and the said policy covered the risk for complainant, his wife Rani, son Deepak and daughter Nirmal.  During the months of April, May and June, 2015 the complainant remained under treatment with Bhagwan Mahavir Hospital, Panipat as indoor and outdoor patient and has incurred more-than Rs.1,50,000/- on his treatment, medicines etc.  The complainant has submitted all the required documents to the respondent for the settlement of the claim.  The complainant has requested the respondent so many times, but ultimately the respondent has refused to make the payment of the claim amount to the respondent 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 purchased PNB Oriental Royal Mediclaim policy valid w.e.f. 9.8.2014 to 8.8.2015 for health insurance covering the risk upto 5 lacs of the complainant and his family members.   As per clause 4 of the policy, the company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of any ailment/disease/injuries/health conditions, 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 3 years of this policy being in force continuously.  It is admitted by the respondent that the complainant has taken the treatment from Bhagwan Mahavir Hospital, Panipat as indoor as well as outdoor patient and has lodged his claim with the respondent.  The respondent company shall not be liable to make any payment under this policy in respect of the expenses whatsoever incurred by the complainant in connection with the treatment, hospitalization etc. as the policy in question has been purchased by the complainant for the first time which is valid w.e.f. 9.8.2014 to 8.8.2015 and thus, the claim of the complainant is not liable to be paid under the policy conditions.  The complainant has not suffered any mental agony, harassment at the hands of the respondent and there is no deficiency in service on the part of the respondent and 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 he has purchased  a PNB Oriental Royal Mediclaim policy for health insurance from the respondent valid w.e.f. 9.8.2014 to 8.8.2015 and the said policy covered the risk for complainant, his wife Rani, son Deepak and daughter Nirmal.  During the months of April, May and June, 2015 the complainant remained under treatment with Bhagwan Mahavir Hospital, Panipat as indoor and outdoor patient and has incurred more-than Rs.1,50,000/- on his treatment, medicines etc.  The complainant has submitted all the required documents to the respondent for the settlement of the claim.  The complainant has requested the respondent so many times, but ultimately the respondent has refused to make the payment of the claim amount to the respondent 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 purchased PNB Oriental Royal Mediclaim policy valid w.e.f. 9.8.2014 to 8.8.2015 for health insurance covering the risk upto 5 lacs of the complainant and his family members.   As per clause 4 of the policy, the company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of any ailment/disease/injuries/health conditions, 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 3 years of this policy being in force continuously.  However, it is admitted by the respondent that the complainant has taken the treatment from Bhagwan Mahavir Hospital, Panipat as indoor as well as outdoor patient and has lodged his claim with the respondent.  The respondent company shall not be liable to make any payment under this policy in respect of the expenses whatsoever incurred by the complainant in connection with the treatment, hospitalization etc. as the policy in question has been purchased by the complainant for the first time which is valid w.e.f. 9.8.2014 to 8.8.2015 and thus, the claim of the complainant is not liable to be paid under the policy conditions.  The complainant has not suffered any mental agony, harassment at the hands of the respondent and there is no deficiency in service on the part of the respondent.

          In the present case, the respondent insurance company has relied upon clause 4 of the policy and has submitted that the company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured.  But in our view, the disease Hepatitis the said clause is not applicable to the disease i.e. Hepatitis.  The complainant has placed on record the copy of receipt of Rs.59600/- and Rs.43000/- (Rs.25000 +Rs.18000).  Since the complainant has incurred the above said amount on his treatment during the validity of the insurance policy, definitely the complainant is entitled to get the said amount from the respondent.

          The complainant has incurred the amount on the purchase of the medicines vide Annexure C-6, 8,11,12,13,14 and 15 i.e. Rs.1200/-, Rs.549/-, Rs.5210/-, Rs.303/-, Rs.2698/-, Rs.1799/-, Rs.3350/-,  Rs.11000/-, Rs.850/-, Rs.1050/-  respectively total amounting to Rs.28009/-. Accordingly, we hereby direct the respondent to make the payment of Rs.1,02,600/- (Rs.59600 + Rs.43000) and Rs.28009/- to the complainant  within a period of 60 days from the date of passing of this order, failing which, the above said amount shall fetch interest at the rate of 09% per annum from the date of passing of this order till 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:23.05.2016