Nisha Nath Ojha
- In the instant case the Complainant has sought for following reliefs against the Opposite party:-
- To direct the opposite party no. 1 and 2 to pay the insured amount of Rs. 3,00,000/- along with 12% interest.
- To direct the opposite parties to pay Rs. 50,000/- ( Rs. Fifty Thousand only ) as Compensation.
- To direct the opposite parties to pay Rs. 10,000/- ( Rs. Ten Thousand only ) as Litigation costs.
- The facts of this case lies in a narrow compass which is as follows:-
The complainant has asserted that after getting her examined by the panel Doctors and considering the medical report the opposite party no. 1 has issued a policy under Silver Health Policy Plan in favour of the complainant. The total sum assured in aforesaid policy is Rs. 3,00,000/- and policy was effective from 31.12.2010 to 30.12.2011 as will appear from annexure – 2.
It has been further asserted that during the life time of the policy, the complainant suffered some problem for which she consulted Doctor who advised for some test for appropriate diagnosis. The complainant completed all necessary test as per advise of the Doctor. After persuing the report etc. Doctor advised her for surgery. Thereafter she was admitted in Max Health care Super Hospital, New Delhi where she was operated on 02.12.2011 as she was suffering from L4 – L5 Spondylolishesis ailment. After operation she was discharged on 06.12.2011 from the hospital. The discharge summary has been annexed by the complainant as annexure – 3. After the operation the husband of the complainant filed a petition for cashless facility which was denied by opposite parties(vide annexure – 4). However opposite parties advised her husband to file a claim petition for reimbursement of the expensed amount after payment of bill to the hospital. As the complainant had no option she had to pay the entire amount of Rs. 3,56,326/-.
After filing the claim as per advise of opposite party no. 1 the complainant furnished all the relevant papers as will appear from annexure – 5 which is the letter of the husband of the complainant.
The opposite parties have rejected the claim of the complainant vide annexure – 1.
On behalf of opposite parties a show cause/written statement has been filed admitting the issuance of the policy. In Para – 9 of the aforesaid show cause/written statement following facts have been asserted by opposite parties, “that the insurance company after scrutiny of papers submitted by the complainant such as Doctor Prescription and Discharge Summary repudiated the claim of the complainant as the same was out of scope of coverage under the terms and conditions of the Bihar health Insurance since surgery on joints falls under exclusion clause © of the policy.”
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From bare perusal of annexure – 2 it is crystal clear that opposite parties have not annexed any terms and conditions with the policy bond. In the policy bond it is no where mentioned that L4-L5 are not covered under this policy.
On behalf of opposite parties, annexure – A has been filed in which the certain conditions has been mentioned in a very small letters. The complainant asserts that at the time of issuing annexure – 2 no such conditions were explained to the complainant and when the complainant requested to pay the insured amount then these conditions have been made applicable with sole intention of not paying the claim amount. This fact has not been denied by the opposite parties in their show cause/written statement.
From bare perusal of discharge summary i.e. annexure – 3 it is crystal clear that the complainant had some pain in her back since 6 months thus it is crystal clear that she was not having such decease at the time of issuance of annexure – 2.
For the reason stated above we find and hold that by rejecting the claim of the complainant vide annexure – 1, the opposite parties have committed gross deficiency for which the opposite parties are jointly and severally liable.
For the reason stated above, we direct the opposite parties to pay the insured amount of Rs. 3,00,000/- ( Rs. Three lack only ) to the complainant within the period of two months from the receipt of this order or certified copy of this order failing which opposite parties will pay 10% interest on the above said amount of Rs. 3,00,000/- ( Rs. Three lack only ) till its final payment.
Opposite parties are further directed to pay Rs. 25,000/- ( Rs. Twenty Five Thousand only ) to the complainant by way of compensation and litigation costs within the period of two months.
Accordingly this complaint stands allowed to the extent referred above.
Member President
