DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,<br /> BATHINDA (PUNJAB)<br /> <br /> CC No. 55 of 03-02-2010<br /> Decided on : 24-05-2010 <br /> <br /> 1.Gurjinder Singh S/o Sukhmander Singh aged 37 years<br /> 2.Veerpal Kaur W/o Gurjinder Singh aged 37 years<br /> both residents of V. Bajoana, Tehsil & District Bathinda.<br /> .... Complainant<br /> Versus<br /> <br /> 1.Bajaj Allianz General Insurance Company Limited, GE Plaza Airport Road, Yerwada, Pune, through its Managing Director.<br /> 2.Bajaj Allianz General Insurance Company Limited, 3038/A, 2nd Floor, Guru Kanshi Marg, Near HDFC Bank Ltd., Bathinda through its Branch Manager<br /> ..... Opposite parties<br /> <br /> Complaint under Section 12 of the Consumer Protection<br /> Act, 1986.<br /> <br /> QUORUM <br /> <br /> Ms. Vikramjit Kaur Soni, President<br /> Dr. Phulinder Preet, Member <br /> Sh. Amarjeet Paul, Member<br /> <br /> For the Complainant : Sh. K.S. Bhullar, counsel for the complainant <br /> For the Opposite parties : Sh. Sanjay Goyal, counsel for the<br /> opposite parties. <br /> <br /> O R D E R<br /> <br /> VIKRAMJIT KAUR SONI, PRESIDENT<br /> <br /> 1. The complainants have purchased Insurance policy No. 0G-09-1212-6002-00000428 for a sum of Rs. 1,00,000/- valid from 13-01-2009 to 23-12-2009 and paid premium of Rs. 2338/- on the same day. The complainants were insured for personal accident and for any disease. The complainant No. 2 suffered from Cholelithiasis (Gall Bladder) and got herself admitted in the hospital of Dr. Harnek Singh Bhangu of Bhangu Surgical Centre, Hazi Rattan Bathinda and remained there from 11-08-2009 to 20-08-2009 and her Gall Bladder was removed. She spent Rs. 13,200/- on her treatment but on 28-10-2009, the opposite parties repudiated the claim of the complainants on account that for two years their claim was not maintainable and the disease from which complainant No. 2 suffered did not fall under terms and conditions of the policy. <br /> 2. The opposite parties have pleaded in their written reply that they have rightly repudiated the claim of the complainants as according to the conditions mentioned under title Health Guard Policy Document in Clause C (2) “What we will not pay”, their Insurance policy does not cover many diseases including Cholelithiasis. The parties have led evidence in support of their respective pleadings. <br /> 3. Arguments heard and written submissions submitted by the parties perused. The complainants are holders of Health Guard Policy issued by Bajaj Allianz General Insurance Company Limited. The complainant No. 2 got operated for Cholelithiasis (Gall Bladder) and she applied for the claim. Her claim was repudiated on the ground that the terms and conditions of the said policy does not cover the disease. <br /> Condition No. C (2) of the Insurance policy Ex. R-3 is reproduced hereunder :- <br /> “C. What we will not pay<br /> We will not pay for claims arising out of or howsoever connected to the following :<br /> 2) Without derogation from C (1) above, any Medical Expenses incurred during the first two consecutive annual periods during which you have the benefit of a Health Guard Policy with us in connection with any types of gastric or duodenal ulcers, cataracts, benign prostatic hypertrophy, hernia of all types, hydrocele, all types of sinuses, fistulae, haemorrhoids, fissure in ano, dysfunctional uterine bleeding, fibromyoma endometriosis, hysterectomy, stones in the urinary and biliary systems, surgery on ears /tonsils/adenoids/paranasal, sinuses, surgery for any skin ailment, surgery on all internal or external tumours/cysts/nodules/polyps of any kind including breast lumps with exception of Malignant tumor or growth. This exclusion period shall apply for a continuous period of a full 4 years from the date of your first Health Guard Policy with us if the above referred illness were present at the time of commencement of the policy and if you had declared such illness at the time of proposing the policy for the first time.” <br /> Thus, as per Condition No. C (2) of the Insurance policy Ex. R-3, it has been specifically mentioned that the opposite parties will not pay the claim in the case of stones in the urinary and biliary systems.<br /> The complainants alleged in their complaint that they have received cover note only and no terms and conditions were ever served to them whereas from the perusal of Insurance policy Ex. C-2 produced by the complainants themselves before this Forum, under the heading 'Other Details' against Wording 3 , it has been mentioned that “all terms, conditions and benefits as per the policy clause (Health Guard and Personal Accident) attached. Thus, at the time of sending Insurance policy, terms and conditions were attached meaning thereby that the opposite parties have sent the terms and conditions of Health Guard and Personal Accident alongwith policy/cover note. As per Ex. C-4 repudiation letter, the repudiation date is 28-10-2009. On detailed scrutiny of the same, we find that the claim does not fall under the purview of policy for the reason given below :<br /> “Verification of the claim documents reveal that the patient is diagnosed of Cholelithiasis and has undergone cholecystectomy. Medical expenses incurred towards treatment on stones in billiary system have a waiting period of two years in the policy. Hence, claim is not payable under policy.” <br /> 4. From the above discussion, this Forum concluded that complainant No. 2 was suffering from Cholelithiasis and has undergone cholecystectomy. This disease is not covered under the said policy. Hence, there is no deficiency in service on the part of the opposite parties. Therefore, this complaint is dismissed without any order as to costs. Copy of this order be sent to the parties concerned free of cost and file be consigned.<br /> Pronounced<br /> 24-05-2010 <br /> (Vikramjit Kaur Soni)<br /> President<br /> <br /> <br /> (Dr. Phulinder Preet)<br /> Member<br /> <br /> <br /> (Amarjeet Paul) Member <br />