This revision follows against the order dated 20/8/2019 delivered by Ld. DCDRF, Siliguri in CC no. 44 of 2019. The fact of the case in nutshell is that one N Dalmia got a Medicare health policy in the year 2014 by paying a proper premium amount which was accepted by the United India Insurance Company limited of Siliguri Branch. Thereafter, his wife got a tooth operation at  Gangaram Hospital at Delhi on 11/3/2016 under the care of Dr. Dewan and Dr. Jain and spent huge amount for such treatment. The complainant Nabin Dalmia then raised a claim before the Insurance Company for reimbursement of the costs for the alleged operation which was conducted within the policy period. The Insurance Company has  repudiated such claim as per terms and conditions of clause no. 4.8 of the Insurance Policy on 30/3/2017. The complainant then submitted a review petition before the insurance Company on 29/5/2017 but no reply was given on the part of the insurance company. Then the complainant lodged grievance petition before the insurance ombudsman on 25/7/2017 and the ombudsman rejected the said petition which was communicated to him on 15/7/2019 and adviced to move any forum or court against the Insurance company for its alleged deficiency in service. The complainant then registered a claim within months from the date of receipt of such advice of ombudsman which was communicated to the complainant vide letter dated 8/7/2019 and the said communication letter was received by the complainant on 15/7/2019. The Ld. Forum at the point of admission has decided that the claim was rightly repudiated due to existence of clause no. 4.8 in the terms and condition of the policy and on the other ground that cause of action was barred by law of limitation. The revision was admitted on its own merit and due notice was sent to the Ops insurance company who in spite of receiving the notice  of revision in due time, did not come here to contest the case. The revision is heard in presence of Ld. Advocate of the revisionist Mr. PD. Dalmia.

Decision with reason,

After hearing the Ld. Advocate of the revisionist. It appears to us that the Ld. Forum has delivered the impugned order on two grounds.

First, as per condition in clause 4.8 of the policy, the claim of the complainant was not sustainable and secondly the complainant did not come to lodge the consumer compliant within statutory period, that is, within two years from the date of repudiation. Here in this case, the complainant revisionist certainly a consumer who has purchased health policy from the insurance company by paying the proper premium amount and he has every authority to raise claim for any medical reimbursement. He had incurred money for the treatment of the insured. He feels that there is deficiency of service on the part of the of the insurance company that is service provider. He has every right to register a consumer complaint. The claim of the consumer was held as bad in law at the admission point which is not desirable one or to hold that the complainant has no locus standi to register a consumer complaint. Whether the claim of the complainant is sustainable or not in view of clause 4.8 of the insurance policy is a mix question of law and the fact and without hearing the case on merit and without giving proper opportunity to the complainant for adducing evidence in support of his case, there was no necessity to hold on the part of the ld. Forum that the consumer complaint was not maintainable in law.

Secondly, the claim of the complainant was repudiated on 30/3/2017. He had the legal right to move before the insurance ombudsman against the decision of the management of the insurance company. The ombudsman has rejected the said grievance petition of the complainant on 8/7/2019 and thereafter the ombudsman has adviced the complainant to  move before any competent court or Forum for his grievances against the insurance company and thereafter within month from the date of such communication, the complainant came to approach before the Ld. Forum for his redressal and Ld. Forum without going through the merit of the case has hold that the claim of the complainant was barred under section 24(b) of the CP Act, 1986. This adjudication on the part of the ld. Forum is not desirable at all, where a bonafide consumer has registered consumer complaint to get  reliefs which has been provided in the CP Act, 1986. So, the order of Ld. Forum seems to be irregular and not vested in law and is liable to be set aside.

Thus, the revisional petition is allowed on merit.

Hence, it is,

Ordered,

That the revisional application be and the same is hereby allowed on merit without imposing any cost. The order dated 20/8/2019 delivered by Ld. DCDRF, Siliguri of CC no. 44/S/2019 is hereby set aside.

The Consumer complaint filed by the revisionist N K Dalmia and his wife A Dalmia, under section 12 of the CP Act, 1986 are hereby admitted on merit. The Ld. Forum is asked to issue notice upon the Ops, asking them to contest the dispute by filing the WV on or before 21/1/2020. The revisionist is directed to take proper steps before the Ld. Forum on 21/1/2020. Let a copy of this  order be communicated to the Ld. DCDRF, Siliguri and also supply the copy of order to the parties of this revision free of cost.