JUDGEMENT

          Complainantby filing this complaint has alleged that complainants hold jointly a Medical Insurance Policy with op no.1 effective from 1991-92 and that policy is valid and continuous in nature without any break even for a day till now and is absolutely claim-free for last 21 years except in one occasion.

          Thereafter complainant for her treatment submitted the claim bearing No.CCN MD10945838 of Rs.59,501/- submitted on 09.05.2011 for hospitalization of complainant no.2 Ashima Bhattacharya (mascular hole surgery).  Another claim No.CCN MD10985930 of Rs.8,550/- submitted on 18.06.2011 to op no.2 directly by speed post from Chennai for post-surgery medical check-up of complainant no.2 Ashima Bhattacharya.  Another case No.CCN MD10985930 for Rs.27,039/- on 18.06.2011 to op no.2 along with all papers for Cataract surgery of complainant.  Those claims are pending against Policy No.311202/48/2011/3041 valid from the period 27.10.2010 to midnight of 26.10.2011.  But surprisingly the claim was repudiated under Clause 4.3 by the op during the said policy as a first year policy.  So they invoked an exercise exclusion clause 4.3 and rejected the claim.  Against that repudiation the complainant made reconsideration petition and thereafter filed a complaint/appeal before the Hon’ble Ombudsman and Ombudsman ordered on 27.03.2008 and Ombudsman in his final judgement came to a conclusion that the Insurance Company to treat the Mediclaim Policy as continuous policy available to the insurer from 1991-92 for future claim if any.  But even after Ombudsman order, the Insurance Company did not consider the complainant’s claim though the entire policy of the complainant is holding continuous policy as yet for more than 21 years and in the above circumstances, complainant has prayed for payment of the entire amount including harassment cost etc.

          On the contrary op by filing written objection has submitted that the present case is not tenable and particularly the complaint is defective, repudiation was made as per Clause 4.3 and the policy period from 2009-10 covers the period from 21.08.2009 and is from 27.10.2010 to 26.10.2011.  So, there is a break in the policy and as such the policy is considered as fresh policy and for which it was repudiated and further the extension of going abroad under individual Mediclaim Policy is allowed only on taking Overseas Mediclaim Policy from Oriental Insurance Co. Ltd.  So the op as per I.R.D.A. Rules has got no other option but to close the claim as ‘no claim’  under policy condition clause 4.3 and denied and also submitted that the complainant is not entitled to any claim and prayed for dismissal of this case.

                                              Decision with reasons

          Most interesting factor is that in this case op failed to give any justified explanation about the order of the Ombudsman because Ld. Insurance Ombudsman vide his verdict dated 27.03.2008 declared that renewals are valid and policy is continuous from 1991-92 up to date even if in the meantime complainant took some Overseas Policy from other company for op’s inability to give appropriate such policy to the complainant during their foreign tour and even after order of the Ld. Insurance Ombudsman till now ops have not complied with the order of the Ld. Ombudsman and also has not filed any appeal against the order of Ld. Insurance Ombudsman.  The Ld. Ombudsman already came to a conclusion that complainants’ Insurance is valid for 21 years or now 23 years old and it is continuous in nature and there is a break and free validity and before leaving India, complainant personally received the continuation of the policy and that continuity break free validity was granted by the then Branch Manager and extended extra date of the complainant before renewal of the cheques and received of the same and issued of the policy by the Branch Manager.  But anyhow on behalf of the op a plea was taken that no extension is allowed unless the Overseas Policy is purchased from the op.  But it is unthinkable because Oriental Insurance Company failed to issue such policy to the complainant at the relevant time and Ld. Ombudsman in this regard already passed such order.  So, under any circumstances, the cause of repudiation of the claim by the op is found illegal and another factor is that as per provision of law Insurance Company is bound to pay as per the direction and order of the Ld. Ombudsman.  But that has been refuted by the op, though op contested in the said proceeding and ultimately failed to prove their plea that ops’ repudiation was justified and as it was the fresh policy.

          Considering all the above fact and circumstances and also relying upon the judgement of the Ld. Ombudsman who decided the matter on contest after considering all the documents produced by the ops and complainant and decided that the Mediclaim Policy is continuous policy purchased in the year 1991-92 for future claims and he has also directed the ops to consider the prayer of the insured with regard to giving coverage of Rs.1.50 lakhs for premium of Rs.1 lac as per revised premium rate as it was done in the year 2006-07.

          Further from the judgement of Ld. Ombudsman passed on 27.03.2008 it is clear that Insurance Company in so many manners deprived the complainant and that was reflected in the decision.  But truth is that on 27.03.2008 Ld. Ombudsman passed his verdict against the op and directed to clear the same on 27.03.2008 in Ombudsman Complaint Case No.284/2013/005/NL/08/2007-08, but even then ops were silent, it indicates that op has adopted unfair trade practice and they have their no desire to comply the verdict of the Insurance Ombudsman though they are guided by that judgement.  It indicates that they are not willing to comply the order of the Quasi Judicial Authority also.  So, it is proved that complainant is entitled to get the insured claim and their claim is certified by the Ld. Ombudsman in that proceeding.  Op failed to prove their genuinity but even they are not giving the effect of that order.

          So, considering that fact we are convinced that the complainants are entitled to insurance claim in respect of the 3 claims as submitted by him to the op and no doubt ops are bound to pay the same when the complainants are being harassed in so many manners since 2008 and in the above circumstances, we are convinced to hold that the repudiation made by the op is illegal which has been decided by the Ld. Ombudsman.  But standing upon that order of the Ld. Ombudsman, op is not paying the same for which we are convinced that the op is an dishonest company and they adopted unfair trade practice and they are trying to deceive the policy holders in so many manners and they are not willing to comply the order of any court what proves harassment as sustained by the complainant no doubt for arrogant, un-merchantable attitude of the op Insurance Company and for which we are convinced to hold that they should be penalized and proper action should be taken against for such Insurance Company for their such sort of arbitrary activities and for not compliance of the verdict by the op insurance company.

          Thus the complaint succeeds.

          Hence, it is

                                                           ORDERED

          That the complaint be and the same is allowed on contest with cost of Rs.10,000/- against the op.

          Ops are directed to clear all the entire amount of the Mediclaims amount as submitted by the complainant within one month from the date of this order along with compensation or Rs.1,00,000/- to the present complainant.

          For causing mental pain, harassment and agony and also for violating the order of the Ld. Insurance Ombudsman which went against the op insurance company in favour of the complainant and for adopting unfair trade practice and also for harassing the insured in so many manners, ops are imposed punitive damages of Rs.50,000/- which shall be paid to this Forum by the ops and it is imposed only to check and control the un-merchantable and unfair trade practice practiced by op in such a manner to cheat the insured in such a manner and also to control their such activities so that in future no insured must be harassed by the ops in such a fashion or deceived.

          Ops are directed to comply this order very strictly within one month from the date of this order (on receipt of the copy of this order) failing which penal action shall be started against them and for that reason also for non-compliance of the Forum’s order within the stipulated time for each day’s delay penal interest @ Rs.300/- shall be assessed till full satisfaction of the decree and even penal proceeding u/s 27 of C.P. Act 1986 shall be started and said amount if collected same shall be deposited to this Forum.

          Op is also directed to deposit another Rs.10,000/- which was confirmed by the State Commission against as per order No.14 dated 18.02.2014 and it shall be deposited to this Forum as penalty separately other than previous order as passed in the ordering portion of this judgement.

          [In this case particular immoral act on the part of the op is found since 21.09.2012 till 24.02.2014.  Fact remains that on two occasions op went to State Commission for various reasons that were rejected by the Hon’ble State Commission and op was bound to pay Rs.10,000/- that was not paid as penalty which was imposed.  So, the said amount shall be deposited by the op to this Forum also.]