District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.166/2021.
Date of Institution: 22.03.2021.
Date of Order:12.09.2022.
Baldev Raj Gupta S/o Sh. Balwant Rai R/o H.No.2-K/28, N.I.T. Faridabad
…….Complainant……..
Versus
The Oriental Divisional Office 5-B/4, B.P., Railway Road, N.I.T. Divisional Manager Faridabad Limited, Second Floor, through its Divisional Manager.
…Opposite party……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………..Member
PRESENT: Sh. Deepak Nagpal, counsel for the complainant.
Sh. Neeraj Kumar, counsel for opposite party.
ORDER:
The facts in brief of the complaint are that the complainant was the holder of Medical Claim Policy vide Policy No. 272400/48/2019/14919 valid from 30.03.2019 to 29.03.2020. The complainant has diagnosed with Acute Asthmatic. Bronchitis with Shock and for that complainant was admitted at Dr. Rahul Mittal Memorial Hospital, Panipat from 12.08.2019 to 16.08.019 and have taken treatment from the said hospital. It was submitted that opposite party’s office was duly informed about admission and treatment of the complainant in the hospital for reimbursement of the claim as per policy of the opposite party within 24 hours of the admission of the complainant vide Claim No. 20324947. Thereafter, the claim process was initiated and complainant had submitted all the original relevant documents to the concerned TPA within stipulated time period. Complainant was again assured by the representative of the opposite party that claim would be approved at the earliest. The complainant was shocked to receive a letter dated 07/11/2019 from the office of opposite party on 09.11.2019 in which it was mentioned that his claim has been repudiated as non genuine and as per Clause no. 5.1. It is further mentioned in the said letter that the claim does not fall within the preview of the policy terms and conditions and as such claim of the complainant was rejected. The claim of the complainant has been rejected by the opposite party without any reason. It had not been mentioned that what were the grounds on which it was found that claim of the complainant was non genuine and on what basis the claim has been rejected. It was further submitted that the complainant had duly submitted all the documents as per requirement of the opposite party but the complainant was surprised to receive the aforesaid letter mentioning therein that his claim is non-genuine. As per the policy complainant terms had submitted all the required documents. In case any other document was required by the opposite party then the complainant was ready to submit the same in the office of opposite party. The complainant many times requested the opposite party to approve his claim but when the opposite party did not give any heed to requests and reminders complainant then the the genuine of the complainant moved an application before the opposite party on dated 19/11/2019 vide which the complainant has requested the opposite party to reconsider his claim and reimburse the same at the earliest. When the complainant did not receive any response from the side of the opposite party then the complainant moved another letter to the opposite party on dated 13/01/2020 but all in vain. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) make the payment of treatment charges alongwith interest @ 24% P.A. from the date of making the payment i.e. 16.08.2019 till its actual final realization;
b) pay Rs. 5,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 21,000 /-as litigation expenses.
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that the complainant had neither any cause of action nor locus standi to file the present complaint. The answering opposite party had rightly declined the claim of the complainant as per clause No.5.1 of the policy and issued a repudiation letter dated 07.11.2019 to the complainant. Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite party– Oriental Insurance Company Ltd. with the prayer to: a) make the payment of treatment charges alongwith interest @ 24% P.A. from the date of making the payment i.e. 16.08.2019 till its actual final realization. b) pay Rs.5,00,000/- as compensation for causing mental agony and harassment .c) pay Rs. 21,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Baldev Raj Gupta, Ex,C-1 – PNB- Oriental Royal Mediclaim policy Schedule valid from30.03.2012 to 29.3.2013,,Ex.C-2 – letter dated 19.11.2019, Ex.C-3 – letter dated 13.01.2020, Ex.C-4 – repudiation letter dated 07.11.2019, Ex.C-5 – email, Ex.C-6 – indoor bill, Ex.C-7 – Bill, Ex.C-8 - Receipt No. 9452 dated 12.08.2019,, Ex.C-9 - bill dated 14.08.2019, Ex.C-10 – receipt No. 677 dated 16.08.2018, Ex.C-11 – Reimbursement claim form, Ex.C-12 – Cash memo, Ex.C-13 – adhaar card.
On the other hand counsel for the opposite party strongly agitated and
opposed. As per the evidence of the opposite party Ex.RW1/A – affidavit of Ramesh Kumar, senior Divisional Manager, Oriental Insurance Co. ltd., Faridabad
6. In this case, the complainant has obtained mediclaim Policy bearing No. 272400/48/2019/14919 valid from 30.03.2019 to 29.03.2020. The complainant has diagnosed with Acute Asthmatic. Bronchitis with Shock and for that complainant was admitted at Dr. Rahul Mittal Memorial Hospital, Panipat from 12.08.2019 to 16.08.019 and have taken treatment from the said hospital. Opposite party had repudiated the claim of the complainant vide letter dated 07.11.2019 (Ex.C-4) on the ground” As per investigation report it was observed that this 70 years old male admitted with acute illness and managed conservatively. As per investigation report the claim is non genuine. Hence, this claim is considered for repudiation as per clause No.5.1.”
7. After going through the evidence led by the parties, the Commission is of the opinion that when the insured is above 63 years then the Insurance Company was at liberty to get the complainant medically examined prior to issuance of the policy in question. Insurance Company cannot take advantage of its act of omission and commission as it is under obligation to ensure before issuing the policy in question whether a person is fit to be insured or not. It was the duty of the opposite party to get the complainant immediately examined before issuing the policy as per IRDA guidelines.
8. The ground of rejection of claim does not stand to the test of scrutiny because opposite party has not placed on record any credible evidence to prove their case. Therefore, not releasing claim of the complainant amounts to deficiency in service on the part of opposite party.
9. Resultantly, the complaint is allowed. Opposite party is directed to process the claim of the complainant within 30 days from the date of receipt of the copy of order and pay the due amount to the complainant alongwith interest @ 6% p.a from the date of filing of complaint till its realization. The opposite party is also directed to pay Rs.2200/- as compensation on account of mental tension, agony and harassment and Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties free of costs and file be consigned to record room.
Announced on: 12.09.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
