I am 70 and had taken medical insurance six years ago. Last year, I had some visual problems, for which I consulted an ophthalmologist. He diagnosed my condition as age-related macular degeneration (ARMD) and advised me treatment with some injections in the eyes in June 2021.
I lodged a claim for medical reimbursement after completing my treatment. But the insurance company denied my claim as this condition falls under their exclusion clause and also because there was no hospitalisation done for the treatment. I approached the ombudsman, who sanctioned 50% of my claim amount. Is there any way of getting full claim reimbursement?
MR Jagyani, Chembur
Due to advancement of technologies in the medical field, even the treatment of ARMD nowadays does not require hospitalisation. Considering these developments, the Insurance Regulatory and Development Authority of India had issued guidelines on September 27, 2019, which have listed a few medical conditions that are not allowed to be excluded from the benefit of the policies. Under Chapter II, Clause 1 (G) specifically mentions ARMD as one of the health conditions that is not allowed to be excluded. It is thus clear that the insurance company cannot repudiate your claim.
You have also mentioned that the ombudsman sanctioned you 50% of your claim. This shows the legitimacy of your claim. You have not stated the reason why only 50% of your claim amount has been sanctioned. This requires due consideration while taking further steps. But overall, you have a good case to approach the District Consumer Disputes Redressal Commission.
I purchased a flat in Thane vide registered agreement dated May 4, 2014, and got soft possession on June 14, 2019, to carry out interior and furniture work. At the time of giving me possession, the builder had not received an occupation certificate (OC). The builder received OC only in October 2020. During the last rainy season, there was a lot of leakage from the roof; I am on the top floor. I requested the builder to do the needful, but he is not ready to do any repair work claiming it is not his liability now. What should I do?
Sandeep Mankar, Thane
The Real Estate (Regulation And Development) Act, 2016 (RERA) has burdened the builder with the responsibility of rectifying such structural or other defects, if they have been brought to his notice within five years from the date of possession. Section 14 (3) of RERA states that “in case of structural defect or any other defect in workmanship, quality or provision of services, it shall be the duty of the promoter to rectify such defects without further charge, within 30 days where such defect is brought to the notice of the promoter
within a period of five years by the allottee from the date of handing over possession”. The Act further provides for the “appropriate compensation” where the promoter fails to rectify such defects within such time.
Also as per Section 13(4)(a) of RERA, the promoter is responsible for all such obligations till the conveyance of all the apartments, plots or buildings or the common areas has been done to the association of allottees or the competent authority.
In your case, since you have taken possession in June 2019, and informed the builder about the leakage problem in July 2022, ie within a period of five years, he is responsible to rectify the defect. If he refuses to carry on such work satisfactorily, you can approach MahaRERA authority for claiming compensation.
It is not clear from your question whether you had any written communication with the builder. If not, it is better to serve him a letter to carry on the repair / water proofing work, before approaching MahaRERA.
Since The Consumer Protection Act, 2019 has defined “defect” as “any fault, imperfection or shortcoming in the quality, quantity, potency, purity or standard which is required to be maintained by or under any law”, the leakage problem you are facing falls squarely under this definition. Thus, alternatively, you may opt to file your complaint before the Consumer Disputes Redressal Commission.
You will have to approach District Commission if the consideration paid by you for this flat is less than Rs50 lakh and State Commission if the consideration paid is more than Rs50 lakh but less than Rs2 crore. If you have paid more than Rs2 crore, you will have to approach the National Commission, New Delhi, irrespective of the amount you incur towards the repair work.
Section 69 of the CPA, 2019, has prescribed a limitation period of two years from the date on which the cause of action arises. In your case, the cause of action arose in July 2022, when you noticed the leakage the first time and you have informed the builder accordingly. Thus, you are well within the period of limitation to file your complaint before the CDRC.
Please note that you can approach only one of these authorities and not both of them.
(Dr Archana Sabnis is an expert on consumer laws who is practising at consumer disputes redressal fora at district, state and national levels since 2000. She is on the panel of conciliators of MahaRERA and is associated with the Mumbai Grahak Panchayat.)
