Padma Pandey, Member
MA 498 of 2021
This application has been filed by the appellant for producing judgments and recalling the order. Arguments on the application have been heard and this application is partly allowed, the judgments are ordered to be taken on record. As far as contention with regard to the recalling of the order is concerned, the same is infructuous in view of the order passed in main case i.e. Appeal No.21 of 2020.
APPEAL NO.21 OF 2020
This appeal is directed against an order dated 23.10.2019, rendered by District Consumer Disputes Redressal Forum-I, UT, Chandigarh, now District Consumer Disputes Redressal Commission-I (hereinafter to be called as the District Commission only), vide which, it partly allowed the Consumer Complaint bearing No.116 of 2018, filed by the complainant, with the following directions: -
“11. In view of the above discussion, the present consumer complaint succeeds and the same is accordingly partly allowed. OPs are directed as under :-
to pay the sum assured of Rs.1,00,000/- to the complainant alongwith interest @ 9% per annum from the date of repudiation i.e. 9.7.2017 till realization.
to pay an amount of Rs.15,000/- to the complainant as compensation for causing mental agony and harassment to him;
to pay Rs.10,000/- to the complainant as costs of litigation.
12. This order be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
The facts, in brief, are that complainant had retired from M/s Tata Motors Ltd., Jamshedpur on 21.10.2005 and his employer had secured a Medi-Claim Policy for the complainant and his wife, namely
Smt. Charanjeet Kaur for a period of 10 years effective from October 2005 till 31stOctober 2015. It was stated that the policy was to expire on 31.10.2015, therefore, in order to secure the continuous benefits of the policy, he approached his employer, who suggested to contact the Opposite Party/Insurance Company for its renewal. It was further stated that after a lot of struggles, the policy was renewed initially w.e.f. 01.11.2015 to 31.10.2016 and thereafter from 01.11.2016 to 31.10.2017, copy of the policies are annexed as Annexure C-5 and C-6. It was further stated that in the first week of May, 2017, the complainant’s wife felt severe pain in her knee and after examination by the Fortis Hospital, knee surgery was conducted and the claim was submitted for reimbursement to the Opposite Parties but, it was repudiated on the ground that 48 months had not expired and the reimbursement of knee surgery was not permissive within 48 months from the date of its issuance. It was further stated that the total bill paid by the complainant for the surgery of his wife was Rs.2,37,947/- (Annexure C-8), but in the policy, the sum assured was Rs.1,00,000/- which was not reimbursed. It was further stated that the aforesaid acts of the Opposite Parties, amounted to deficiency, in rendering service.
The Opposite Parties No.1 & 2 filed their joint reply and stated that sum assured per policy was Rs.1,00,000/- and the claim of the complainant fell in the exclusion clause 4.3, which was not payable within 48 months from the date of issuance of the policy. It was further stated that as per previous policies of Tata Motors, Opposite Parties are ready to pay Rs.54,000/- and not Rs.1,00,000/- due to exclusion clause. It was further stated that there is no deficiency in service on its part, and the Opposite Parties had prayed for dismissal of the complaint.
None had turned up on behalf of the Opposite Party No.3, as a result whereof, it was proceeded against ex-parte, by the District Commission, on 8.6.2018.
In the rejoinder filed by the complainant, he reiterated all the averments, contained in the complaint, and repudiated those, contained in the written version of the Opposite Parties No.1 and2.
The parties led evidence, in support of their case.
After hearing the Counsel for the Parties, and, on going through the evidence, and record of the case, the District Commission, partly allowed the complaint, as stated above.
Feeling aggrieved, the instant appeal, has been filed by the appellant/Opposite Party No.1.
We have heard the Counsels for the parties, and have gone through the evidence, and record of the case, carefully.
After giving our thoughtful consideration, to the contentions, advanced by the Counsel for the appellant, and the evidence, on record, we are of the considered opinion, that the appeal is liable to be dismissed, for the reasons to be recorded hereinafter.
On-going through the record of the learned District Commission, we have observed that the policy issued by the appellant’s company were operative for the last more than a decade and subsequent thereto they are renewed by the appellant’s company. The appellants themselves has furnished a self-contradictory reply by first adhering to the exclusion clause and then diluting it to say that they are ready to pay Rs.54,000/- on account of previous policies, is suggestive of the fact that the claim of the respondent ought not to have been repudiated for the full sum assured (Rs.1.00 lac). It is further observed that the policy was in continuity i.e. from the year 2005 and the period of four years had already expired in the year 2009 or to say 2010 and the claim of the treatment is of the year 2017. It is very well apparent that the insurance policy is in the continuity for the last more than 12 years as on the date of institution of instant consumer complaint and as such the learned District Commission observed that the said complaint falls within the parameters of the terms and conditions of the insurance policy and held the insurance company liable for def
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iciency in service and allowed the said complaint to the extent as discussed above. Going by the above discussion, the appeal, being devoid of merit, must fail, and the same is dismissed, with no order as to costs. The order of the District Commission is upheld. No other point, was urged, by the Counsel for the parties. For the reasons recorded above, the appeal, being devoid of merit, must fail, and the same is dismissed, with no order as to costs. The order of the District Commission is upheld. Certified copies of this order, be sent to the parties, free of charge. The file be consigned to Record Room, after completion.