The complainants Sri Arun Kumar Jalan and Smt. Seema Jalan have filed this complaint petition against Chief Manager, The Oriental Insurance Company Ltd., Oriental House Ashafali Road New Delhi and one another for realizing of Rs. 1,91,887/- as medi claim, Rs. 10,000/- for physical and mental harassment & Rs. 10,000/- as litigation cost., Total Rs. 2,11,887/- from o.ps with 12 % interest p.a. from the date of filing of the complaint petition.
The brief facts of the case is that complainant no.1 got treatment of his wife ( complainant no.2) smt. Sima Jalan who is beneficiary of medi claim policy for ailment of Post Menu Pausal bleeding and multiple fibroid uterus of Lilawati hospital and Research centre Mumbai. It is further alleged that after treatment she resumed her health. It has been further mentioned that RS. 1,91, 887/- was expended in treatment of disease , operation, medicine and bill of hospital. It is further mentioned that the complainant claimed Rs. 1,91,887/- as claimed no.2349487/- from o.ps for payment of the same but after long gap of the time the o.ps neither repudiated the claim nor paid the claimed amount till 26-11-2012. It has been further mentioned that on 18-09-2012 o.p. informed the complainant that he will be informed soon after disposal of the claim. After lapse of much time the complainant sent a legal notice on 03-04-2013 and prayed for payment of amount but o.ps neither replied legal notice dated 03-04-2013 nor paid the claimed amount.
The complainant has filed the following documents with the complaint petition - photocopy of Medi claim policy annexure-1, photocopy of pharmacy detail of Lilawati Hospital & Research Centre annexure-2, photocopy of Medical certificate annexure-2 (I), photocopy of statement of final settlement annexure-2 (II), photocopy of claim form annexure-2 (III), photocopy of repudiation letter annexure-2 (IV), photocopy of letter regarding receiving of claim annexure-3, photocopy of request letter by complainant for disposal of claim as earliest annexure-4, photocopy of legal notice annexure-5
The o.ps appeared on 18-02-2015 and filed their w.s. on 01-09-2015 with prayer to reject the complaint case summarily . It has been mentioned in the w.s that the complaint case is not maintainable in eye of law as well as on fact. It has been further mentioned that the complainant wrongly and illegally made o.p. no.1, The Chief Manager, The oriental insurance company. Ltd. as a party in the complaint case where as the divisional manager is only authorized person to settle the dispute claim within specified territory. It has been further mentioned that the claimant has got no cause of action or right to sue against the o.ps. O.ps has admitted of issuance of medi claim policy bond in the name of complainant no.1 in which complainant no.2 is beneficiary. It has been mentioned in para – 9 of the w.s. that Smt. Seema Jalan was admitted in Lilawati hospital on 21-05-2012 for the treatment of her disease, Post Menu – Pausal bleeding and hysterectomy was done. It has been further mentioned that as per present policy condition, the said ailment comes under purview of conditions of policy under exclusion no. 4.1 and 4.2 which is not payable in first two years.
It has been further mentioned that repudiation was granted to the complainant on the terms and conditions in para 4.1. it has been further mentioned that company of the o.p had also given a chance to substantiate his claim to the complainant on 20-04-2015 but the complainant failed, to respond about their claim, which shows the tendency/ negligence of the complainant regarding settlement of this false and fabricated claim.
On behalf of o.ps following documents have been annexed - photocopy of P.N.B and Oriental royal medi claim policy schedule annexure-A, photocopy of prospectus of PNB oriental royal medi claim policy annexure-B, photocopy of letter dated 20-04-2015 & 20-09-2012 sent to Mrs. Seema Jalan and Mrs. Arun Kr. Jalan from Divisional Manager, Oriental Insurance Company Ltd., annexure-C
Issuance of medi claim policy bond in the name of complainant no.1 is an admitted fact and in the same the complainant no.2 is beneficiary. Treatment of Sima Jalan in Lilawati Hospital for treatment of her disease ( Post Menu Pausal bleeding and hysterectomy ) policy is also an admitted fact. In photocopy of prospectus of PNB oriental royal medi claim policy annexure-B, para- 4.1 following conditions have been mentioned – “pre-existing health condition or disease or ailment/injuries: Any ailment/disease/injuries/health condition which are- pre-existing (treated/untreated, declared/not declared in the proposal form), when the cover incepts for the first time are excluded up to three Completed) years of this policy being in force continuously. For the purpose of applying this condition, the date of inception of this Mediclaim Policy taken from The Oriental Insurance Company shall be considered, provided the renewals have been continuous and without any break in period.
In the same prospectus in para-4.2 The the expenses of treatment of Hysterectomy for menorrhagia or fibromyoma or myomectomy or prolapse of uterus. Ailment/diseases/surgeries for the period of 2 years are not payable if contracted and/or manifested during the currency of the policy.
If these disease are pre-existing at the time of proposal the exclusion no. 4.1 for pre –existing condition shall be applicable in such cases.”
The medical policy was taken on 05-04-2011 and its period of insurance was from 05-04-2011 to midnight of 04-04-2012. It was extended from 05-04-2013 to 04-04-2014. Life assured smt. Seema Jalan was admitted in Lilawati Hospital on 21-05-2012 and operated in the same period. That period of operation is within 2 years of the proposal of the policy. The disease which was treated in Lilawati Hospital comes within purview of prospectus of PNB oriental royal policy in para-4.2. So, we are of the considered opinion that there is no deficiency on part of o.ps and as such the complaint petition is not maintainable and liable to be dismissed.
In the circumstances the complaint petition is dismissed without cost.
