Sri S.K.Sahoo,President.

                The   complainant has filed  this  complaint U/s. 12 of  C.P.Act, 1986.

2.       The  case of the  complainant is that he  has purchased a Hospitalization Benefit policy (Individual claim)  bearing policy No. 16380048098500000120 floated   by  the opp.parties for  a  sum  of  Rs.2,50,000.00. The  said  policy  was   valid  from 01.08.2009 to 31.07.2010 mid night. The  premium  amount  was Rs.9761.00. Annexure-1 is  the  photo copy of the   policy issued by the opp.parties in favour of the  complainant. While  the  policy was  in full  force the  complainant  suddenly fell ill and  treated at Kalinga Hospital,Bhubaneswar in  Cardiac Science  Department. The  treating  doctor diagnosed the  same  as  coronary artery with hypertension .The  complainant was  never ill   prior  to such illness. As the  condition  of the   complainant  deteriorated  on 31.05.2010, surgery was  conducted on the  complainant. He  was dis-charged  from the  hospital  on 08.06.2010. Annexure-2 is the photo copy of the bill issued  by  Kalinga Hospital, Bhubaneswar for the  treatment  of the  complainant. Soon after the complainant was ill, he  informed  about the  same  to the opp.parties. On 29.12.2011  the   complainant  received  a letter  from the opp.parties and  came  to  know  about the  repudiation of  his  claim  by opp.parties. Annexure- 4 is  the  photo copy of the   repudiation letter  of  opp.party No.1.

3.       In pursuance of notice the opp.parties entered his appearance and  submitted  written statement on 18.07.2013. The case of the opp.parties is that the   complaint   filed  by the    complainant is not  maintainable  and there  is  no  cause  of action to file this case. The  complainant is  not a consumer as  defined C.P.Act. The case filed by him is barred  by law of  limitation. The  complainant had  applied  for  Hospitalization Benefit policy ( Individual claim) in  his name  along with  the name of  his  wife  Anita Chawda. The opp.party  issued  the  policy which  was  valid  from 01.08.2009 to mid night  of  31.07.2010 .The  complainant  also  renewed  the  policy  for the period  01.08.2010  to 31.07.2011  bearing  policy No.1638/48/10/8500000614. In the  condition of the  policy it  has been categorically mentioned that the  company shall not be  liable to  make  any payment  under the  policy in respect of  any expenses  what  soever incurred  by  any  person  in  connection  of   with,  in respect of :  all diseases  injuries are  pre-existing   when the  cover  incepts  for  the  first time  during  the  first  one  year  of the  operation  of   the  policy  expenses on treatment  of  benign  ENT disorders & surgeries like  Tonsillectomy/ Adenoidectomy/ Mastoidectomy /  typanoplasty as per clause 4.1 and 4.3 of the policy. As per the complaint petition the  complainant was ill on 30.05.2010 and  after surgery discharged from the  Kalinga Hospital  on 08.06.2010 .The  first year of  policy started from 01.08.2009  to 31.07.2010 . Hence the   coronary artery  with hypertension  is  not  covered  as per the  policy condition. So  after  taking  into  consideration the  exclusion  clause under  paragraph- 4.1 and 4.3 the  complainant  is  not  entitled to  get any  relief. The  case  may  be dismissed.

4.       The complaint petition filed by the complainant is supported with affidavit. Annexure-1 is the photo copy of   Hospitalization Benefit Policy bearing  No. 16380048098500000120 issued on 31.07.2009 by  the opp.party  in favour of the  complainant. The  policy was   for  the  complainant and  his  wife.  An amount of Rs.15,690.00  was paid  towards the  premium for  both of  them. Out of the  said   premium amount  an amount  of Rs.9781.00 was paid  as premium for the  complainant  and  the   sum assured was Rs.2,50,000.00. In the  complaint petition  the  complainant has  vividly  described  about  his  treatment  at Kalinga Hospital. Annexure-2  shows the amount spent by the complainant in the  aforesaid  hospital  for  his  treatment. The  contents of the  complaint  petition  regarding  the  illness of the  complainant  and  his  treatment  at Kalinga  Hospital is  supported  with  documents. So  it is  clear  that the  complainant  was  ill  on 30.05.2010 for  which  he was admitted  to Kalinga  Hospital and  surgery  was  conducted on  him by the  doctors on 31.05.2010. It is  also clear that the  complainant  was  discharged  from the  hospital on 08.06.2010  after   his  slight  recovery.

5.       In the  written  statement  the  opp.party at  paragraph-5  admitted  about the issuance  of the policy to  the  complainant  which  was  valid  from 01.08.2009 to 31.07.2010. At paragraph-6  it is  also  admitted that the  policy was  renewed which covered from 01.08.2010 to 31.07.2011 vide policy No.163800/48/10/8500000614. It is also admitted by the opp.party  in the  written statement  that the  policy was issued  for  hospitalization  benefit of the  insured. However, at  paragraph-7 it  has been mentioned that  due  to  exclusion clause under 4.1 & 4.3  the  complainant is  not  entitled  to  get any  benefit.  Annexure-4 filed by the complainant is the photo  copy  of letter  received by  him from  the opp.party, by which the opp.party has repudiated the  claim , basing on the  exclusion clause- 4.1 & 4.3  of the  standard  medical claim policy. On perusal of the  photo copy of  policy Annexure-1  there is endorsement  as  follows:-

“IN WITNESS THEREOF, the undersigned being duly authorised hereunto set his hand at “This Insurance shall not extend to pay any expenses incurred relating to the disease(s)/sickness/injury mentioned in this column and for consequences attributable thereto or accelerated thereby or arising therefrom”.

It is  clear  from the  aforesaid  endorsement  that the  insurance  shall not  extended to pay any expenses incurred relating to the diseases(s)/sickness/injury mentioned in  this column for  consequences attributed there or  accelerated  there by  or  arising  there  from. Surprisingly there is no such  column  in Annexure-1 which shows the  description  of  disease(s)/sickness/injury. However, during  argument the Learned Counsel for the opp.party filed a specimen copy of  prospectus and submitted that it  has been  clearly  mentioned in the   prospectus  about Clause-4,4.1,4.3. On perusal  of the last page of the prospectus  it  is clear  that  the  said  prospectus shall form part of the  proposal form, for which the  insured  should  sign the  prospectus. There  is  a  space and column for  signature  and the date of signature. The existence of such prospectus  and  communication  of the  contents there of  does not appear on Annexure-1. There is no reason why the opp.party failed to produce the  original proposal  form and  prospectus executed by the  complainant in favour of the opp.party. The  complainant has  discharged the  onus on him  by  proving a  valid  policy issued   by the opp.party    in  his  favour  and  about his  treatment  within that  period. Now the onus  shifts  to the opp.parties to prove that the  prospectus  which includes the  exclusion  clause  was duly communicated to the  complainant at the time of  issue of   Hospitalization  Benefit  Policy  issued in his favour. The  opp.party  utterly  failed to  prove his case. By  issuing  no  claim letter to the  treating  doctors and the  complainant   by the opp.party also shows  adoption of  unfair  trade practice  along  with  deficiency in service. Normally  such  conduct  of the opp.party caused  harassment ,mental agony   to the  complainant.

6.       Hence  order :-

: O R D E R :

          The opp.party is directed to  pay an amount of  Rs.50,000.00  (Rupees Fifty Thousand ) only along  with interest @ 9% p.a  from 08.06.2010  till payment  is made. The opp.party   further  directed  to pay an  amount of Rs.40,000.00 (Rupees Forty Thousand )only as compensation and Rs.20,000.00 (Rupees Twenty Thousand) only towards  litigations expenses as  this  is  a case of the year 2012. The aforesaid amount is to  be  paid by the  opp.party  within  one  month  of  receipt of this order, failing which  he  is  liable to pay penal  interest @ 12% p.a until payment is  made.