That the Complainant joined CRISIL Ltd. Mumbai on 29/12/2005 in a service agreement. CRISIL Ltd. had taken a mediclaim policy from Opposite Party i.e. ICICI Lombard General Insurance Co. Ltd. for their employees and their parents. As such, the Complainant and his parents were also covered under the policy from 29/12/2005 till 07/09/2006. On 08/09/206 the Complainant joined a new company, Opus Financial Services. There was no facility given by new employer to the Complainant for health insurance. Since, the Opposite Party was ex-policy provider, the Complainant contacted Opposite Party for renewal of mediclaim policy for the Complainant and his parents. He had requested Opposite Party to renew his mediclaim policy on 14/09/2006. Agent from Opposite Party came to the Complainant on 19/092006, after a delay of 5 days from the date of request. The Complainant gave 3 cheques to the agent of Opposite Party on 19/09/2006 for renewal of his mediclaim insurance policy. Agent of Opposite Party told the Complainant that he will renew the said three policies because the rule of insurance company is to renew the policy within 15 working days from the date of expiry of old policy and further told that the Complainant will get a No Claim Bonus of 5 % on the renewed policy.
 

2) It is the case of the Complainant that inspite of renewing old policy, Opposite Party issued the new policy which was valid from 25/09/2006 to 24/09/2007. The Complainant has produced photo copy of the said policy alongwith Exhibit-“B”. The Complainant had asked for renewal of policy within 7 days and had given cheques within 12 days from the expiry of the first policy. It is submitted that the Complainant was entitled to get renewal of policy and No Claim Bonus.
 

3) It is submitted that the Complainant became ill and was admitted to Suchak Hospital from 12/10/2006 to 20/10/2006. During aforesaid period, the Complainant was treated in the hospital for Acute Pancreatitis. It was not pre-existing disease. After discharge from the hospital Complainant submitted his claim to the Opposite Party alongwith hospital bills. However, Opposite Party has repudiated his claim on the ground that claim is not admissible as per Sec.3(2) of policy as it was presented in the first 30 days of the policy.
 

4) Thereafter Complainant approached Insurance Ombudsman, however, the Insurance Ombudsman dismissed case of the Complainant subsequently the Complainant filed an appeal with Insurance Regulatory and Development Authority but, same was also rejected by IRDA. Therefore, the Complainant has filed this complaint before this Forum.
 

5) The Complainant has requested to consider his policy as renewed policy and direct Opposite Party to pay his mediclaim and subsequent expenses with adequate interest. The Complainant has also prayed for compensation, mental agony and harassment and he has also requested to direct Opposite Party to pay the cost of this proceeding.
 

6) Alongwith complaint, the Complainant has filed photo copy of documents i.e. page no.5 to 16.
 

7) Opposite Party has filed written statement and thereby denied the claim of the Complainant contending interalia that this Forum has no jurisdiction to entertain to try this complaint as this complaint involves complicated facts and law. It is submitted that the complaint is misconstrued and does not disclose any cause of action therefore it is liable to be dismissed with cost. 
 

8) It is the case of the Opposite Party that hospitalization within 30 days from inception of the policy is not covered whereas admittedly, the Complainant has hospitalized within 30 days of inception of Individual Health Care Policy effective from 25/09/2006 to 24/09/2007. The Complainant’s Individual Health Care Policy was incepted from 25/09/2006 and the Complainant was hospitalized on 12/10/2006 i.e. within 30 days from inception of the said policy therefore, the claim was repudiated by the Opposite Party vide its letter dated 13/11/2006. It is conducted that after due scrutiny of the document submitted by the Complainant the Opposite Parties has rejected claim of the Complainant by giving elaborate reasoning for the rejection, as such, there is no deficiency of service on the part of Opposite Party. 
 

9) It is submitted by the Opposite Party that the Complainant was earlier covered under Group Insurance Policy issued by Opposite Party in favour of M/s.CRISIL Ltd., ex-employer of the Complainant. The Complainant’s services with M/s.CRISIL Ltd. were terminated on or about 07/09/2006. The aforesaid policy issued by the Opposite Party in favour of M/s.CRISIL Ltd. was Group Insurance Policy therefore, there is no question of renewing the said policy by the Complainant hence, the Complainant was advised to obtain Individual Health Care Policy. The Complainant paid premium after 12 days and the proposal of the Complainant was accepted on or about 25/09/2006. Individual Health Care Policy was a new policy and it was effective from 25/09/2006 to 24/09/2007. The policy certificate is produced on record by the Complainant. The Opposite Party has produced Standard Terms and Conditions of the Individual Health Care Policy alongwith written statement at Exhibit-‘I’. Opposite Party has denied allegations that the policy issued to the Complainant on 25/09/06 was renewed of Group Mediclaim Policy. 
 

10) The Opposite Party has denied allegations that their agent approached the Complainant to renew Group Mediclaim Policy and it is admitted that the Complainant issued cheques on 19/09/2006 and after due scrutiny the Complainants proposal was accepted on or about 25/09/06. The Opposite Party has denied allegations that there is any rule to renew policy within 15 working days as alleged. Further it is denied that agent told the Complainant that he would get ‘No Claim Bonus’ of 5 % on the alleged renewal of the policy. 
 

11) The Opposite Party has replied upon relevant clause 3.2 of mediclaim policy and submitted that as such, claim was within 30 days from the date of inception of policy which was repudiated by the Opposite Party and Ld.Insurance Ombudsman considering the aforesaid provision of clause 3.2 has rightly dismissed case of the Complainant. 
 

12) Opposite Party has denied allegations made in the complaint para no.21-27. It is submitted that this Forum has no jurisdiction to scrap the conditions of the policy. According to the Opposite Party provision of clause 3.2 of mediclaim policy has been designed to avoid specific claim for pre-existing disease and this Forum have no jurisdiction to set aside the said clause as alleged. It is submitted by the Opposite Party that the Complainant is not entitled to any relief or claim and this complaint is liable to be dismissed with cost. 
 

13) Alongwith written statement, Opposite Party has produced documents as per list of document i.e. copy of Standard Terms and Conditions of Individual Health Care Policy, copy of repudiation letter dtd.13/11/2006, etc.
 

14) The Complainant has filed rejoinder and thereby denied allegations made in the written statement. The Complainant has filed written argument, the Opposite Party has also filed written argument. The Opposite Party has filed pursis on 14/12/2009 stating that their written argument may be treated as their oral argument. Heard oral argument of the Complainant. 
 

15) Following points arises for our consideration and our findings thereon are as under – 

 

 

 

 

 

 

 

 

Reasons :- 

Point No.1 :- Following facts are undisputed facts – that on 29/12/2005 the Complainant joined CRISIL Ltd. Mumbai. The CRISIL Ltd. had taken a medical policy from Opposite Party i.e. ICICI Lombard General Insurance Co.Ltd. for their employees and their parents. The Complainant being employee of CRISIL Ltd. the Complainant and his parents were also covered under the policy from 29/12/2005 till 07/09/2006. The Complainant left CRISIL Ltd. and joined a new company i.e. Opus Financial Services on 08/09/206. Opus Financial Services had not taken Mediclaim Health Insurance Policy for their employees. Therefore, the Complainant contacted Opposite Party for renewal of mediclaim policy for himself and his parents. As per the Complainant, on 19/09/2006 the agent of Opposite Party came to the Complainant and that time the Complainant gave him 3 cheques to fill mediclaim form.
 

        It is the case of the Complainant that he had paid premium on 19/09/2006 to the agent of Opposite Party for renewal of earlier mediclaim policy however, Opposite Party issued new policy and the said policy was valid from 25/09/06 to 24/09/2007. Photo copy of the said policy is produced by the Complainant alongwith complaint at Exhibit-“B”. According to the Complainant he has applied to the Opposite Party for renewal of policy and therefore, it was necessary on the part of to renew the policy however, the Opposite Party has issued new policy and it amounts to deficiency in service on the part of Opposite Party. It is further submitted by the Complainant that renewal of policy is on the same terms and conditions. In support of his contention he has relied upon decision of Delhi High Court in the matter of Mukut Lal Duggle V/s. United India Insurance Co. Ltd., reported in 2006 ACJ 1576 in which it is held that “if an insured is already covered under an insurance policy, say, a group mediclaim and wants to take an individual policy, the same may be issued up to the identical sum insured on the same terms and conditions if there is no break”. It is submitted by the Complainant that within 7 days from date of first policy he made request for renewal however, agent of Opposite Party approached after 5 days from the date of request on 19/09/06 he paid cheques and new policy was issued by the Opposite Party which was valid from 25/09/06. According to the Complainant there was no delay on his part and it was necessary for the Opposite Party to renew the said policy. 
 

        According to the Opposite Party CRISIL Ltd. had obtained Group Insurance Policy. On the contrary it is submitted by the Opposite Party that Opposite Party had issued Group Mediclaim Policy to their employees. Complainant was covered under the said Group Mediclaim Policy. The Complainant left service of CRISIL Ltd. on or about 07/09/2006 and joined service of Opus Financial Services on 08/09/2006. Thereafter the Complainant approached Opposite Party for renewal of mediclaim policy. Infact, the said policy was issued by the Opposite Party to CRISIL Ltd. It was Group Mediclaim Policy for the employees of CRISIL Ltd. After the employee left the job of CRISIL Ltd. he was not entitled for renewal of Group Mediclaim Policy issued to CRISIL Ltd. Therefore, the Opposite Party issued fresh Individual Health Care Policy. Photo copy of which is produced by the Complainant. Even according to the Complainant, during relevant period his new employer was Opus Financial Services Ltd. and he was not the employee of CRISIL Ltd.
 

           It is admitted facts that on 29/12/05 the Complainant joined CRISIL Ltd. CRISIL Ltd. which had obtained Mediclaim Policy for their employees and their parents while the Complainant in service of CRISIL Ltd. he was covered under the said policy. The Complainant left job on 07/09/06 and joined in service of Opus Financial Services on 08/09/06. Thereafter the Complainant approached Opposite Party and paid premium allegedly prayed for renewal of policy. Infact, the earlier policy was renewed in favour of CRISIL Ltd. It was Group Mediclaim Policy. After the Complainant left service of CRISIL Ltd. he was not entitled for renewal of policy issued in the name of CRISIL Ltd. As the facts of the present case are totally different than the facts stated in the aforesaid reported decision therefore, aforesaid decision relied upon by the Complainant is not applicable to the present case. It is clear from the record that after receipt of the premium from the Complainant the Opposite Party on or about 25/09/2006 issued new Individual Health Care Policy to the Complainant which was valid from 25/09/2006 to 24/09/2006.
 

         As per the Complainant on 12/10/06 he became ill and was admitted in Suchak Hospital. On 12/10/06 to 20/10/06 he received treatment in Suchak Hospital for Acute Pancreatitis. He has produced medical case papers of Suchak Hospital and bills of medicines, etc. and after discharged from the hospital he submitted his claim under the mediclaim policy to the Opposite Party. The Opposite Party has repudiated the claim as per mediclaim policy condition 3.2 on the ground that the claim arose within 30 days form the inception date of the policy. Opposite Party has produced terms and conditions of General Health Care Policy. As per clause 3.2, “Mediclaim charges within the 30 days on inception dated of the policy except those that are incorrect as a result of bodily injury caused by an accident. The exclusion does not apply for subsequent of renewal with the company without a break. 
 

         It is submitted by the Complainant aforesaid clause 3.2 in the mediclaim is arbitrarily and unjust and he has requested to scrap clause 3.2 in the policy. It is well settled that Consumer Forum has no jurisdiction to scrap or set aside any terms and conditions of the contract executed between the parties. In this case new Individual Health Care Policy was issued to the Complainant for the period from 25/09/2006 to 24/09/07 during the period of aforesaid policy within 30 days from the date of inception of policy i.e. on 12/10/06. As such, the Complainant’s aforesaid mediclaim expenses within 30 days from the date of inception of the policy, as per the clause 3.2 of Individual Health Care Policy the Opposite Party has rejected claim of the Complainant. As Opposite Party has rejected claim of the Complainant as per the terms and conditions of the policy it cannot be said that there is deficiency in service on the part of Opposite Party. It appears that after rejection of claim by the Opposite Party the Complainant approached Insurance Ombudsman, however, his complaint was rejected by the Insurance Ombudsman. The Complainant produced copy of order dtd.10/09/07 passed by Insurance Ombudsman. After rejection of complaint by Insurance Ombudsman the Complainant approached Insurance Regularity & Development Authority. However, his appeal was also rejected by Insurance Regularity & Development Authority. Therefore, considering facts of the case we hold that the Complainant has failed to prove deficiency in service on the part of Opposite Party. In the result we answer point no.1 in the negative. 
 

Point No.2 :- With discussion above the Complainant has failed to prove deficiency in service on the part of Opposite Party. The Complainants incurred medical expenses in question within 30 days from the date of inception of the policy and therefore, as per clause 3.2 of Mediclaim Policy the Complainant is not entitled to recover his medical expenses from the Opposite Party as well he is not entitled for ‘No Claim Bonus’ facility or any other relief from the Opposite Party. Hence, we answer point no.2 in the negative.
 

For the reasons discussed above, the complaint deserves to be dismissed hence, we pass following order -
 

O R D E R

 

i.Complaint No.136/2008 is dismissed with no order as to cost.