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2026 Supreme(Online)(SCDRC) 1211
IN THE DELHI STATE CONSUMER DISPUTES REDRESSAL COMMISSION
Sangita Dhingra Sehgal, President, Bimla Kumari, Member
SH RAMESH KUMAR – Appellant
Versus
ORIENTAL INSURANCE CO .LTD – Respondent
FIRST APPEAL NO. – 215/2023 | FA/215/2023
For the Appellants/Petitioners: Santosh Tiwari
For the Respondents: Sujeet Keshari
An insurance company cannot raise belated objections regarding the age of the insured after renewing the policy for several years; such inaction and failure to settle a claim constitute a deficiency in service and unfair trade practice.
Headnote:The appellant filed a complaint under S.12 of the Consumer Protection Act 1986 seeking reimbursement of medical expenses amounting to Rs. 88,500/- for his wife's treatment under a Mediclaim policy. The insurance company failed to settle the claim, citing discrepancies in the insured's age and late intimation of the claim. The District Commission initially dismissed the complaint as premature on the grounds that the claim had not been formally repudiated. The primary issue was whether the insurance company's failure to settle the claim, despite the policy being renewed for several years, constituted a deficiency in service. The court reasoned that since the policy had been subsisting and renewed for 7–8 years without any prior objection to the age of the insured, the company was estopped from raising a belated objection regarding age. Furthermore, the court found that the company had been intimated of the hospitalization as evidenced by the denial of a cashless facility request. Resultantly, the present Appeal stands allowed in the aforementioned terms.
| Table of Content |
|---|
| 1. summary of the medical claim, insurance company's objections, and the district commission's initial dismissal as premature. (Para 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8) |
| 2. arguments regarding the failure to settle the claim and non-compliance with irdai guidelines. (Para 9 , 10) |
| 3. court's review of the record and the respondent's failure to comply with the lower court's order. (Para 11 , 12 , 13 , 14 , 15) |
| 4. estoppel against insurance companies raising belated age objections after years of policy renewal. (Para 17 , 18 , 19 , 20) |
| 5. final award of medical expenses with interest and compensation for mental agony. (Para 21 , 22 , 23) |
PER: HON’BLE JUSTICE SANGITA DHINGRA SEHGAL, PRESIDENT
JUDGMENT
1. The facts of the case as per the District Commission record are:
“Sh. Ramesh Kumar (in short the complainant) filed the instant complaint U/s 12 of the Consumer Protection Act 1986 as amended up to date (in short the Act) alleging therein that he has been taking Mediclaim policy from the Oriental Insurance Company Limited (in short the OP) for the last 07-08 years. On 30.08.2013, he has got renewed mediclaim policy, policy No. Being 272100/48/2014/1006 which also covers his wife and dependent child for a sum insured of Rs. 1,25,000/- and 75,000/- from 30.08.2013 - 29.08.2014. On 02.08.2013, his wife got injured due to some fall of weight on her foot and was taken to the local doctor who administered stitches and prescribes medicines. The injury did not heal, upon which she was taken to family hospital on 20.09.2013 and was advised urgent admission where she underwent immediate operation after undergoing various tests. The OP was intimated immediately on admission to the hospital. The intimation of claim was also sent to the hospital and a confirmation was received by mail. He has forwarded the documents to the OP to settle the claim but in vain. He was informed by the OP that TPA recommendation has been closed due to late intimation of claim to OP but no closure letter has been received by him till today though a bill of Rs. 88,500/- was submitted to OP. The non-settlement of claim shows that there is deficiency of service on the part of OP. The exclusion clauses are never brought to the notice of beneficiaries. The insurance policy was valid at the time of accident but OP did not settle the claim of the complainant because of which he has undergone mental agony and harassment. Hence the instant complaint seeking direction to the OP to pay a sum of Rs. 88,500/- with interest there on @ 24% p.a. from the date of filing of hospitalization, compensation to the tune of Rs. 1,00,000/- for mental agony, pain and sufferings as well to pay Rs. 51,000/- being the cost of litigation and other misc. expenses.”
2. The OP has filed the reply with the averments that the complainant is no maintainable as there is no deficiency in service. The complainant has not replied to the queries and claim lying pending.
3. The complainant has renewed Mediclaim insurance policy from 30.08.2013 - 29.08.2014 and policy was issued. The copy of the same along with terms and conditions is Annexure R1. On 14.10.2013, the claim was reported by the complainant for the reimbursement of the expenses incurred on the treatment of the wife of the complainant. It was noticed on the scrutiny of the documents that on 02.08.2013, the injury was suffered by the wife of the complainant and on 20.09.2013 the patient was admitted to the hospital. The intimation was given to the OP after 74 days of the injuries and 24 days after the discharge from the hospital. The age of the wife of the complainant is reflected as 37 years in the discharge summary and 33 years in the policy. The OP came to the conclusion from all these facts that claim of the complainant is not maintainable since there was waiting period of 07 days as per condition 4.1 of the Policy for limitation of claim under the policy. The complainant vide separate letter was directed to explain
