PRESENT

                   Complainant by Adv. Shri. H.Kumar Vaidyanathan present.                                                        

                  Opponent No. 1 Ex-parte.

                   Opponent No. 2 Absent.  

ORDER

(Per- Mr. S. D. MADAKE, Hon’ble President. )

1.                The complainant filed complaint under section 12 of Consumer protection Act. 1986 against opposite parties for deficiency in service for  repudiating of claim as per contract of Insurance.

2.                The complainant was employee of M/s Reliance integrated Services having code No.35012274 .  All employees have taken Medi-claim policy including complainant.  The opp. No. 1 is third party agent dealing with clearance of any claims in case of accidents.

3.                The complainant met with an accident and was admitted in M.T. Agarwal Hospital, Mulund on 10.7.2009. He was discharged on 16.7.2009.  He was admitted at Chenai Meenakshi Multispecality Hospital during 17.7.2009 to 22.7.2009.

4.                The complainant incurred expenses and submitted claim as per contract of Insurance.  The claim was denied by letter dated 3.11.2010 relying on clause 4.8 of the policy.

5.                The complainant prayed for direction to opposite parties to pay Rs. 1,13,974/-  as  per claim, with interest @ 18 % p.a. with compensation of Rs. 25,000/-.

6.                The opponent No. 1 failed to appear though duly served and also did not file written statement.  We passed order to proceed Ex-parte on 27.12.2016.

7.                The opponent No. 2 appeared and filed written statement on 16.8.2012 and resisted allegations made in the complaint.  It is denied that opp. no. 2 is guilty for deficiency in service and Unfair trade practice.  It is alleged that, complaint is not maintainable and barred by limitation.

8.                The opponent No. 2 stated that, claim is not payable as per exclusion clause No. 4.8 .  It is alleged that, case papers reveal that complainant smell of alcohol, Alcohol intoxication and under influence of alcohol. 

9.                The opponent No. 2 stated that claim is not payable as per condition No. 5.13 i.e. disclaimer clause , failure to make immediate claim as per condition No.5.4 and failure to submit documents within time as per condition  5.5.

10.              The opp. No. 2 stated that complainant has left the company on 30.10.2010.  It is contended that complainant was lying under the influence of drink on 11.7.2009 at 2 p.m.  He failed to inform regarding his treatment at Chenai.

11.              The opp. No. 2 stated that complainant lodged claim of Rs. 67,166/-  which was relating to treatment at Mulund during 11.7.2009 to 16.7.2009 which was repudiated on 1.9.2009 as per policy cl.No.4.8.  It is denied that, complainant is entitle for Rs.1,13,974/- and prayed for dismissal with cost.

12.              We have perused complaint, written statement, written argument, letter dated 14.7.2009 with medical bills, letter dated 17.5.2010 along with additional bills, rejection letter dated 3.11.2010 and receipts of payment.

13.              The complainant stated in written argument and filed on record documents to show that , he paid Rs.14,750/- on 29.8.2005 for treatment at Chennai, Rs.7,050/- , Rs.25,000/- for treatment at Devki Hospital Chennai.  He incurred expenses Rs.67,166/- for treatment at Mulund .  He filed affidavit in support of claim.  The amount of claim is not disputed regarding quantum .

14.              The rejection is on the ground of clause No.4.8 which covers misuse of abuse of alcohol or use of intoxicating substance comes under exclusion clause No. 4.8.

15.              The opponent No. 2 stated that complainant was under influence of alcohol .  As per law, Insurance company has to prove by conducting test that, Insured had in his blood  alcohol.   In the present case, Insurance company failed to prove the exclusion clause by adducing evidence.  Mere notings  in papers is not sufficient to attract clause 4.8 to show that complainant was under the influence  of alcohol.

16.              We hold that, opposite party no. 2 is liable to pay the expenses of Rs. 1,13,974/-  incurred by complainant, for treatment during insurance period. 

17.              The complainant submitted claim within a reasonable time with documents and therefore same cannot be denied on the ground of delay in making claim.

18.              We have carefully perused the bills and receipts of payment and found that, complainant incurred expenses for treatment to the amount of Rs. 1,13,974/- .

19.              The complainant claimed interest on the amount claimed.  The claim pertains to treatment during July 2009 and was repudiated on 3.11.2010.  We award interest from 4.11.2010.

20.              In the result, we pass the following order.

                                                O R D E R

1.                RBT Complaint No. 120/2012 is partly allowed.

2.                ORIENTAL INSURANCE COMPANY is directed to pay to complainant  Rs.1,13,974/- ( Rupees one lacs thirteen thousand

                   nine  hundred seventy four only) with interest @ 6 % p.a. from 4.11.2010 till payment.

3.                No order as to cost. 

4.                Copy of this order be sent to both parties.