ORDER

NIPUR CHANDNA, MEMBER



    Complainant is a mediclaim policy holder of OP no.1 vide policy
no. 110100/11001/1000207097 -01 w.e.f. 15-5-2012 to 13-5-2013.

    It is alleged by the complainant that the time of renewal of the
aforesaid policy in the year 2012 , the OP had lodged an extra premium
of Rs 8000/- whereafter it was agreed that clause 6 (b) would not be
enforcible and the time framed U/s 6 (c) & 6 (d) shall be reduced to
one year and two years respectively.

    It is alleged by the complainant that she had filed a claim for
Rs. 30,148/- regarding treatment of IMSC right  eye of her  husband
who was admitted on 8-5-2013 and was discharged  on 8-5-2013 with OP
on 4-6-2013.  The same was repudiated by the OP with the following
observations-“ the present illness has a specific two years of waiting
period as per the policy and the policy starting date is 14-5-2011.
We regret to inform you that your claim is repudiated under section 6
c of the policy.”

    It is further alleged by the complainant that despit e the fact
that the waiting period under clause 6 C had been reduced to 1 year,
the OP has repudiated his claim on false and flimsy ground.

    The complainant had also filed a complaint before the insurance
ombudsman on 19-7-2013 against the repduation. The insurance ombudsman
vide its order dated 05-2-2015 affirmed the decision of the insurance
company as right.

    Being aggrieved by the decision of the insurance ombudsman ,
complainant approached this forum for the redressal of his grievance.

    Notice of the complaint was sent to the OP through Regd. AD. Post
on 24-4-205. The notice was not received back unserved , service was ,
therefore, presumed was to have been effected on the OP. since none
appeared on behalf of OP, it was ordered to be proceeded with
ex-parte.

    Complainant has filed his evidence by way of affidavit dated
20-8-2015 in which she has corroborated the contents of the complaint.

    We have heard arguments advanced at the bar and have perused the record.

 The complainant has placed on record the copies of health insurance
policies issued by the OP year after year.  She has also placed on
record copy of the award passed by insurance ombudsman dated 5-2-2015
along with its affidavit.

    The complainant has placed on record the copy of the policy no.
110100/11001/1000207097 -01, the bare perusal of the same clarifies
that the waiting period for condition no. 6 c has been reduced to one
year. The complainant has filed his claim for  reinspection before the
OP for the year 2012-2013 which is in the second year of the policy,
and as the waiting period under clause no. 6 C is reduced to 1 year,
the OP ought not to have rejected the claim of the complainant on the
ground that illness is covered under section 6 c for which there is a
waiting period of 2 year.

   This act of the OP amounts to deficiency in services. From the
unrebutted testimony of the complainant as well as the documents
placed on record. We hold OP guilty of deficiency in services and
direct it as under:-

To pay to the complainant Rs 30,148/- along with interest @ 10% p.a.
from the date of filing of complaint till payment.

 To pay to the complainant a sum of Rs. 10,000/- for mental pain and
agony suffered by him.

To pay to the complainant a sum of Rs. 5000/- as cost of litigation.



     The OP shall pay this amount within a period of 30 days from the
date of this order failing which they shall be liable to pay interest
on the entire awarded amount @ 10% per annum.  IF the OP fails to
comply with this order, the complainant may approach this Forum for
execution of the order under Section 25/27 of the Consumer Protection
Act.

    Copy of the order be made available to the parties as per rule.

    File be consigned to record room.

    Announced in open sitting of the Forum on.....................