M. P. STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PLOT NO.76, ARERA HILLS, BHOPAL FIRST APPEAL NO.2083 OF 2014 (Arising out of order dated 17.09.2014 passed in Case.No.537/2012 by District Commission, Satna)

GYANSWAROOP DWIVEDI, R/O GRAM BHAKRA, POST KAKARHATI, DISTT. SATNA. … APPELLANT.

Versus .

1. ORIENTAL INSURANCE COMPANY LIMITED, THROUGH DIVISIONAL MANAGER, CHOURASIA COMPLEX, REWA ROAD, DISTT. SATNA.

2. RAKSHA T.P.A PRIVATE LIMITED THROUGH MANAGER, G-10-G-11, GROUND FLOOR, INDUSTRIAL HOUSE BUILDING, A.B.ROAD, INDORE. .… RESPONDENTS.

BEFORE :

HON’BLE JUSTICE SMT.SUNITA YADAV, PRESIDENT HON’BLE DR. (MRS) MONIKA MALIK, MEMBER COUNSEL FOR PARTIES :

Shri S.R.Soni, learned counsel for the appellant.

None present for respondents.

O R D E R (Passed on .01.2026)

The following order of the Commission was delivered by Dr.(Mrs) Monika Malik, Member :

This is an appeal by the complainant / appellant directed against the order dated 17.09.2014 passed by the District Consumer Disputes Redressal Commission, Satna (for short ‘District Commission’) in complaint case no. 537/2012, whereby the District Commission has dismissed the complaint filed by him. 2. Facts of the case in brief are that the complainant/ appellant had purchased a mediclaim policy bearing no.152700/48/2012/832 from the opposite party no.1/ respondent no.1 - Oriental Insurance Company Limited (hereinafter referred to as ‘Insurance Company’) w.e.f. 05.07.2011 to 04.07.2012 under which sum insured was Rs.50,000/- and hospital limit was Rs.10,000/-. He alleged that he was admitted between 02.11.2011 to 10.11.2011 regarding treatment of malaria / hepatitis in Dayawati hospital, but when he presented the claim in this regard with the Insurance Company, the same was denied on account of clause 4.22 and 5.4 of the policy terms and conditions. He therefore, alleged deficiency in service against the opposite parties.

3. Heard.

4. Perused the record.

5. Learned counsel for the complainant / appellant argued that the District Commission has committed error in holding that no prior intimation was given by the complainant / appellant before admission, whereas the fact is that the complainant / appellant had intimated the Insurance Company before getting admitted in the hospital. He therefore argued that both the clauses based on which his claim has been denied are not applicable in the instant matter. He prayed that the impugned order be set aside.

6. The District Commission dismissed the complaint holding that no intimation within 24 hours of admission or before discharge was given by the complainant / appellant and also no active treatment was received by him.

7. We find that though an intimation dated 02.11.2011 is available on record but the same does not bear any receiving from the Insurance Company. Therefore, it cannot be held that the complainant /appellant had intimated the Insurance Company or TPA before getting admitted. The complainant / appellant has produced treatment papers so as to suggest that the treatment was received by him. Clause 4.22 of the policy terms and conditions is the exclusion with regard to any stay in the hospital for any domestic reason or where no active regular treatment is given by the specialist.

The complainant / appellant has not produced any evidence to contradict this clause. The District Commission has therefore rightly concluded that the complainant / appellant did not receive active regular treatment.

8. Clause 5.4 is with regard to notice of claim, which reads thus:

“5.4 NOTICE OF CLAIM: Immediate notice of claim with particulars relating to policy Number, ID Card No., Name of insured person in respect of whom claim is made, nature of disease / illness / injury and Name and Address of the attending medical practitioner / Hospital / Nursing Home etc. should be given to the Company / TPA while taking treatment in the Hospital / Nursing Home by Fax, Email. Such notice should be given within 48 hours of admission or before discharge from Hospital / Nursing Hom