BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM; FATEHABAD.
Complaint Case No. 37 of 2017.
Date of Instt.: 09.02.2017.
Date of Decision: 20.11 .2017.
Palvinder Singh, aged 55 years son of Inderjeet, resident of village Birabadi, Tehsil Ratia and District Fatehabad.
..Complainant
Versus
1.The Oriental Insurance Company Limited (Government of India Undertaking), Divisional Office, SCO No.174-75, Red Square Market, Railway Road, Hisar District Hisar through its Divisional Manager.
2.The Oriental Insurance Company Limited, Branch Office Fatehabad, Tehsil and District Fatehabad through its Branch Manager.
..Respondents/OPs
Before: Sh.Raghbir Singh, President.
Mrs.Ansuya Bishnoi, Member.
Sh.R.S.Panghal, Member.
Present: Sh.H.S.Sandhu, Adv.for the complainant.
Sh. U.K.Gera, Adv. for the OPs.
The present complaint under Section 12 of Consumer Protection Act, 1986 has been filed by the complainant with the averments that he purchased a Medi-claim policy under P.N.B. Oriental Royal Medi-claim Policy Schedule IRDA/NL-HLT/OIC/P-H/VI/454/13-14 valid from 06.12.2015 to midnight 05.12.2016 from the OPs and a sum of Rs,6,960/- was debited in the account of the complainant bearing account No.0547000101116057 in P.N.B. Bhuna on 19.11.2015. His wife namely Devender Kaur was also covered under the said policy. It is further submitted that Devender Kaur wife of the complainant was admitted in Fortis Hospital, Sector -62, Phase-8 Mohali on 29.07.2016 due to health complications and she remained under treatment in the said hospital and was discharged on 3.07.2016. On account of above said treatment a sum of Rs.55,000/- was charged from the complainant by the hospital. In the affidavit filed by the complainant it is also stated that the aforesaid policy was previously taken by the complainant in the year 2012 and the same remained continued up-to 05.12.2016 without any break. However a genuine insurance claim of the complainant has been repudiated by the OPs without any reason. In this regard a legal notice dated 03.10.2016 was also served to the OPs for making payment of the amount paid by the complainant in the hospital. However no reply to the above said legal notice was given by the OPs. The above said act on the part of the OPs in denying the genuine claim of the complainant amounts to deficiency and unfair trade practice in rendering service to the complainant and the complainant is entitled for a payment of Rs.55,000/- along-with compensation etc. Hence the present complaint.
2. On notice the OPs appeared and resisted the complaint by filing a written statement wherein various preliminary objections with regard to maintainability, cause of action and locus-standi etc. have been raised. On merits it is submitted by the OPs that the date of commencement of the policy in question was 06.12.2015 and the patient was treated/operated within first two years of the date of commencement of policy and according to the terms and conditions of the policy there is a waiting period of 2 years. It is further submitted that the inception of first insurance policy in the present case is 06.12.2015 to 05.12.2016 and the period of admission and discharge from the hospital is 29.07.2016 to 3.07.2016 which is well within the first 2 years of the commencement of the period of insurance which is not covered during the first 2 years of the commencement of policy in question. In an affidavit filed by the OPs it is further submitted that there was a break in the previous policies i.e. between 1st and 2nd policy and between 2nd and 3rd policy. The policy in question is 4th one and there is no break in 3rd and 4th policy. The treatment taken by the patient is within 2 years from the commencement of 3rd policy. Therefore the complainant is not entitled to any insurance claim and as such the present complaint is liable to be dismissed.
3. In evidence the complainant has tendered his affidavit as Ex.CW1/A wherein the averments made in the complaint have been reaffirmed. In support of his case the complainant has also tendered documents Annexure C1 to Annexure C16 and closed the evidence. On the other hand Sh.Sushil Kumar, Divisional Manager, filed an affidavit as Annexure R1 on behalf of OPs and also tendered in evidence the insurance policy as Annexure R2 and closed the evidence.
4. We have heard the arguments advanced by learned counsel for the parties and have also perused the entire material placed on the record of the case. It is the case of the complainant that he purchased a medi-claim policy under P.N.B. Oriental Royal Medi-Claim policy, valid from 06.12.2015 to 05.12.2016 from the OPs and a sum of Rs.6960/- was debited in the account of the complainant. His wife namely Devender Kaur was also covered under the said policy. Therefore Devender Kaur was admitted in Fortis Hospital, Mohali on 29.07.2016 due to health complications and remained under treatment and discharged on 30.07.2016. An amount of Rs.55,000/- was charged from her by the hospital for treatment. It is also the case of the complainant that the aforesaid policy was previously taken by the complainant in the year 2012 and the same remained continued upto 05.12.2016 without any break. But a genuine medi-claim of the complainant has been repudiated by the OPs. On the other hand it is the case of the OPs that the date of commencement of the policy was 06.12.2015 and Smt. Devener Kaur was treated within two years from the date of the commencement of the policy and as per the terms and conditions of the policy of insurance in question there is a waiting period of 2 years. It is also the case of OPs that there was a break in the previous policies i.e. between 1st and 2nd policy and between 2nd and 3rd policy. The policy in question is the 4th one and there is no break between 3rd and 4th policy. The treatment taken by the patient is within two years from the commencement of 3rd policy. Therefore the complainant is not entitled to insurance claim.
5. In the instant case it is not disputed that the policy in question was purchased by the complainant from the oPs and Smt. Devender Kaur wife of the complainant was also covered under the policy. It is also not disputed that Smt. Devender Kaur remained admitted and got treatment form the Forties Hospital from 29.07.2016 to 30.07.2016. The claim of the complainant has been repudiated only on the ground that the treatment was obtained within two years from the date of commencement of the policy and the same was not covered under the policy. We are of the considered opinion that the case of the complainant for grant of medi-claim falls within the purview of the policy in question. A perusal of the record reveals that the 2nd policy was valid from 28.11.2013 to 27.11.2014. A perusal of Annexure C-7 i.e. Account ledger inquiry issued by Punjab National Bank further reveals that an amount of Rs.6830/- as premium has been debited vide cheque No.78602 from the account of the complainant on 20.11.2014 i.e. before 27.11.2014 the completion period of 2nd policy. Therefore if any delay has occurred in issuing the 3rd policy then the complainant cannot be held liable and it cannot he held that there is a break between the 2nd and 3rd policy. Therefore we are of the opinion that there is no break in the policy since 28.11.2013 and the treatment taken by Devender Kaur on 29.07.2016 and 30.07.2016 is after the expiry of two years from the date of commencement of the policy. Moreover from the year 2012 to the year the OPs have received premium from the complainant and now it is not appropriate on the part of the OPs to repudiate the genuine claim of the complainant on technical grounds. It is a settled proposition of law that genuine claim of the insured must not be declined by the insurance companies on technical grounds.
In view of the aforesaid discussion the present complaint is allowed and the OPs are directed to make the payment of Rs.55,000/- to the complainant along-with Rs.5,000/- as compensation on account of mental agony, physical harassment and litigation charges suffered by the complainant. The order be complied within a period of one month. A copy of this order be supplied to both the parties free of cost as provided in the rules. File be consigned after due compliance.
ANNOUNCED IN OPEN FORUM. Dt.20.11.2017
(Ansuya Bishnoi) (R.S.Panghal) (Raghbir Singh)
Member Member President
DCDRF, Fatehabad
