BEFORE THE SOUTH MUMBAI  DISTRICT  CONSUMER DISPUTES REDRESSAL FORUM,

                                                                         O.No.

Complaint No.SMF/MUM/CC/2014/209

   Date of filing :  22/09/2014                                                                                                    

                                                                                Date of Order: 06/10/2017

Vasantray Vithaldas Mody,

1704, Panchratha, Opera House,

New Queens Road,

Mumbai – 400 004.                                              ..… Complainant         

        V/s.

The Oriental Insurance Company Limited,

3^rd Floor, Magnet House, N.M. Marg,

Ballard Estate,

Mumbai – 400 038.                                            ….. Opposite Party

Coram:

Shri. G.K. Rathod                :   Hon’ble President

Shri. S.R. Sanap                   :   Hon’ble Member

Appearance:        Complainant     -     Adv. Smt. Anita Marathe

                              Opposite Party –   Adv. Shri. A.S. Vidyarthi /

 Adv. Smt. Kajrekar

// JUDGMENT//

PER SHRI. G.K. RATHOD – HON’BLE  PRESIDENT

                   The brief facts of the case as stated are as  under :-

                   The Complainant is a Senior Citizen and practicing Advocate (Taxation).  He had taken Individual Mediclaim Insurance Policy from the Opponent by paying appropriate premium amount for the sum assured of Rs.1,50,000/- and the policy was enforced during the period from 20/03/2013 to 19/03/2014.  The Complainant was admitted in hospital for undergoing a surgical procedure under hospitalization benefit, not requiring hospitalization more than 24 hours as per clause 2.3 of the Policy.  The claim was submitted by the Complainant and it was repudiated by the Opponent  on  frivolous ground by letter dtd. 5/3/2014. As aggrieved by the Complainant against the repudiation,   the present complaint is filed alongwith list of documents , affidavit-evidence, written arguments and also heard the oral arguments.

(2)               To rebut the claim, the Opponent has denied all the contents of the complaint and allegations of the Complainant in toto.  The Insurer is not 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 : Expenses incurred at Hospital or  Nursing Home primarily for evaluation / diagnostic purposes which is not followed by an active treatment for the ailment during the hospitalised period.  It is further submitted that the Complainant also underwent Gastroscopy.  Under these circumstances, the Complainant is not entitled to any claim or relief sought by him in the prayer clause of the complaint.

(3)               From the above facts, following points arouse for  determination.

(4)               From the above facts and circumstances and from the contents of the complaint,  affidavit - evidence, written arguments and oral arguments and also written version, affidavit- evidence, written arguments and oral arguments of the Opponent, as it was admitted fact that the Complainant had taken Mediclaim Insurance Policy from the Opponent  during the period from 20/3/2013 to 19/3/2014 and he was hospitalized during that period. When he submitted the claim, the claim was repudiated on 5/3/2014.  As the Complainant was paying regular premium of the policy and policy was in existence,  therefore, we found that  there is a deficiency in service and unfair trade practice on the part of the Opponent as the Opponent repudiated the claim of the Complainant without any reasonable cause  Therefore, the Complainant is entitled for amount of Rs. 38,015/- with interest @ 9% from the date of the complaint till its realization and Rs. 10,000/- for mental harassment and Rs. 2,000/- for litigation charges.

(5)               Accordingly, we proceed to pass the following order :    

//O R D E R//

1. The complaint is partly allowed.

2. The Opponentto pay the amount of Rs. 38,015/- with interest @9% fromthe date of filing this complainti.e.22/09/2014 till its realization to the Complainant.

3. The Opponent also shall pay the amount of Rs. 10,000/- for mental harassment and Rs.2,000/- towards litigation charges to the Complainant.

4. The Opponent to comply the aforesaid order within aperiod of (30) days from the date of receipt of this order.

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

    

                       (Shri. S.R. Sanap)                                       (Shri.G.K. Rathod)

     Hon’ble  Member                                       Hon’ble President

    

   Note:-  As the pleadings, affidavit, documents, written arguments of the parties are in English, the order in the proceeding is passed for the better knowledge of the parties in English.

   vns