Delhi High Court · 2025

$~10 * IN THE HIGH COURT OF DELHI AT NEW DELHI + W.P.(C) 1189/2023 PRIYANKA JAIN .....Petitioner Through: Dr. L.S. Chaudhary, Dr. Ajay Chaudhary, Mr. Bharat Chaudhary, Ms. Vinita, Ms. Monika and Mr. Vishesh Kumar, Advs. versus ORIENTAL INSURANCE COMPANY LIMITED .....Respondent Through: Mr. J. P. N. Shahi and Mr. Shikhar Prakash, Advs. CORAM: HON'BLE MR. JUSTICE SACHIN DATTA O R D E R % 02.05.2025 1. The present petition has been filed by the petitioner seeking that the respondent be directed to reimburse the medical claim of the petitioner amounting to Rs.3,13,318.74. 2. The background of the matter is that late Shri Subhash Chand Jain, father of the petitioner, regularly purchased mediclaim policies from the respondent insurance company starting from 11.07.2012. These policies consistently covered himself as the primary insured and the petitioner as his dependent unmarried daughter. One such mediclaim policy, bearing No. 272900/48/2018/6700, was issued for the period 11.07.2017 to 10.07.2018. Under this policy, the sum insured was ₹5,00,000 and the annual premium paid was ₹6,990. The policy explicitly covered all medical expenses incurred by the insured and the dependent daughter, including hospitalization and treatment costs. The said policy has been filed as This is a digitally signed order. The authenticity of the order can be re-verified from Delhi High Court Order Portal by scanning the QR code shown above. The Order is downloaded from the DHC Server on 01/07/2025 at 23:54:52 Annexure-P2 to the present petition. 3. Since then the policy has been renewed thereafter from time to time. The policy history data is mentioned in the concerned policy. 4. The petitioner is undisputably the beneficiary of the policy. The policy also refers to the petitioner as being unmarried. 5. It is submitted that the petitioner was diagnosed with Large Carbuncle Lower Anterior Abdominal Wall and her surgery was conduced in Max Super Speciality Hospital, Patparganj, Delhi-110092. The said surgery was conducted on 19.01.2018. In connection therewith, the petitioner remained hospitalized w.e.f. 18.01.2018 to 23.01.2018. A bill for Rs.1,90,372.46 (Rupees One Lakh Ninety Thousand Three Hundred Seventy Two and Forty Six Paise Only) was raised by the hospital in connection therewith. 6. Thereafter the petitioner suffered from Uncontrolled Type 2 Diabetes Mellitus Tension Headache and she again remained hospitalized w.e.f. 28.05.2018 to 04.06.2018 in the aforesaid Max Super Speciality Hospital. The hospital raised the bill amounting to Rs.1,22,946.28 (Rupees One Lakh Twenty Two Thousand Nine Hundred Forty Six and Twenty Eight Paise Only). 7. As such, the total amount which the petitioner incurred during the policy period was to the tune of Rs.3,13,318.74. 8. Despite the petitioner being eligible for reimbursement, the concerned claim was not processed by the respondent. 9. During the course of hearing, learned counsel for the respondent has drawn attention to the reply filed on behalf of the respondent wherein it has been stated that the only reason for non-processing / non-payment of the claim raised by the petitioner is that certain documents were not submitted This is a digitally signed order. The authenticity of the order can be re-verified from Delhi High Court Order Portal by scanning the QR code shown above. The Order is downloaded from the DHC Server on 01/07/2025 at 23:54:52 by the petitioner. The relevant communication of the respondent is reproduced as under – <Dear Sir/Madam Ref: Patient Name: Priyanka Jain Policy No: 272900/48/2018/6700 Claim No: 16344052 MAID: 5007469236 Contact No: 8447259290 Insurer Claim No: 272900/48/2018/006585 Insurer Member Id: 2 We confirm the receipt of your claim as per the reference given above. On scrutiny of the documents submitted by you, the following documents/ information would be required for further processing of your claim. We request you to furnish the following at your earliest convenience: Sl. No. Documents Required 1 General Queries  Any government id proof like voter id/ dl/ passport etc-copy  TPA id card-xerox copy 2 OTHERS  Kindly clarify the marital status of the claimant We assure you that on receipt of the above stated information/ documents your claim shall be processed expeditiously. Should you require any clarification do call on our Customer Service Helpline. All the above listed documents required to process the claim are to be furnished within 10 days from the date of this letter. It shall be the sole responsibility of the insured to submit the required claim documents. Please submit the above documents to the respective branch office Processing the claim and Quote our reference No: 16344052 in all your future correspondence 10. Learned counsel for the petitioner refutes that the aforesaid documents were not supplied to the respondent. However, he further points out that all the requisite documents have been appended to the present petition itself. This is a digitally signed order. The authenticity of the order can be re-verified from Delhi High Court Order Portal by scanning the QR code shown above. The Order is downloaded from the DHC Server on 01/07/2025 at 23:54:52

11. In this regard, he drawn attention to Annexure-P6 (Colly) of the present petition, whereby a copy of the petitioner’s Aadhar Card and TPA Card of the petitioner’s father has been placed on record. He further clarifies that the marital status of the petitioner is evident from the perusal of the policy itself. He further submits that an affidavit has been submitted by the petitioner to the respondent affirming that the marital status of the petitioner remained unchanged. 12. In the circumstances, there appears to be no impediment in processing the aforesaid claims of the petitioner. The respondent is directed to process the said claim and make the requisite payment to the petitioner as expeditiously as possible, and in any event within a period of six weeks from today. 13. The petition is disposed of in the above terms. 14. List for compliance on 17.07.2025. SACHIN DATTA, J MAY 2, 2025/cl