ORDER

Per Rakesh Kapoor , President

The complainant had purchased a medical insurance policy from M/s
Reliance General insurance Company Ltd which was valid for the period
11.9.2007 to 10.9.2008.  He had got the policy renewed from 11.10.2008
to 10.9.2009 and for the period 11.9.2009 to 10.9.2010 from the same
insurance company. In the year 2010, the complainant had submitted a
proposal form with OP2 and a policy was issued by it in continuation
of the earlier policies.  The policy issued by OP2 was valid for the
period 11.9.2010 to 10.9.2011 and was renewed for the period 9.9.2011
to 8.9.2012.  It is alleged by the complainant that on 17.6.2011 he
had to be hospitalized at Sir Ganga Ram Hospital and had spent a sum
of Rs. 19,315/- on his treatment.  He had submitted a claim with the
OP which was not paid and has been repudiated.   The complainant
alleges that the repudiation of the claim is unwaranteed and uncalled
for. Hence, the complaint.

The Ops have contested the complaint. oP2  has filed a written
statement wherein it has denied any deficiency in service on its
partand has claimed that the claim has been rightly repudiated.
Para 8 of the written statement is relevant for the purposes of the
decision of this complaint and is being reproduced as under

That the claim was denied by TPA under exclusion clause 4.3 as per
terms and conditions of the above mentioned policy. Copy of the terms
and conditions of the policy annexed as annexure OP2/B.  The inception
date of the policy is w.e.f. 11.9.2010 and the complainant was
admitted in hospital on 18.6.2011. hence the medical expenses incurred
by the complainant was not covered and therefore claim was denied.

    The complainant got fresh policy from OP2 w.e.f. 11.9.2010 which
was not in continuation of his previous policy issued by Reliance
General Insurance.  The complainant was required to follow the
procedure as laid down by IRDA to get the benefit towards importing a
policy. Annexure OP2/ A of IRDA circular dated 9.9.2011 was not
followed by the complainant.

    It was also clarified by TPA OP1 under letter dated 25.8.2011
(annexure C-9) of complaint) to the complainant that under policy
exclusion 4.1. pre-existing diseases coverage will not be available
for an insured person during the first four years since inception of
the first policy with the CO.

    Expl. Note : The “first policy” shall mean the family medicare
policy if insurance is taken for be first time or if previous
insurance with other co.

    The said letter  dt. 25.8.2011of TPA –OP1  bereferred to as in
continuation of letter dt. 1.7.2011 –Annexure C -7 of the complaint.

    The complainant, under his annexure C-4 (colly) intentionally
avoided reference of above exclusion clause 4.1 and 4.3 of the terms
and conditions of the policy. It is clearly suppression of material
fact from the Hon’ble Forum.

    The complainant has not completed four years of medicare policy
(first three years from Reliance General Insurance then from OP2
United India Insurance Co. Ltd 11.9.10to 10.9.2011when he was
hospitalized on 17.6.2011. therefore the claim was denied by the TPA
–OP1.



The OP2 has prayed that the complaint be dismissed.

We have heard arguments advanced at the bar and have perusedthe record.

     The claim lodged by the complainant has been repudiated by the
Ops on the plea that the inception date of the poliy is 11.9.2010 and
the expenses on the treatment are not payable under clause 4.3 of the
policy purchased by the complainant. It is the case of the OP that the
complainant had purchased a fresh policy from it w..e.f. 11.9.2010 and
it was not in continuation of his previous policies issued by M/s
Reliance General Insurance.   In order to prove its defense . It was
incumbent  on OP2 to have placed on record relevant documents
including the proposal form.We had , therefore, directed OP2 to place
on record a copy of the proposal form on the basis of which the policy
in question was issued to the complainant.    Despite several
opportunities granted to OP2, no copy of the proposal form was placed
on record and in fact a statement was made by the learned counsel for
OP2 on 2.7.2014 to the effect that no proposal form was actually
executed at the time of the issuance of the policy in question.  It
is, therefore, clear that the policy in question was issued in
continuity with theearlier policy held by the complainant.In that view
of the matter , the repudiation of the claim by OP2 on the ground that
the policy issued by it was  new policy is not  justified.   We,
therefore, hold that OP 2 wasdeficient in rendering service to the
complainant.   OP2 should have granted portability benefit to the
complainant and considered his claim as per the guidelines of IRDA in
this behalf.  We, therefore, direct OP2 as under :

1.Pay to th complainant a sum of Rs. 11,716/- from the date of
institution of this complaint i.e. 4.10.2011 till payment.

2.Pay to the complainant a sum of rs. 10,000/- as compensation for
paidn and agony suffered by him.

3.Pay to the complainant a sum of Rs. 5,000/- as cost of litigation.



The OP shall pay this amount within a period of 30 days from the date
of this order failing which they shall be liable to pay interest on
the entire awarded amount @ 10% per annum.  IF the OP fail to comply
with this order, the complainant may approach this Forum for execution
of the order under Section 25/27 of the Consumer Protection Act.

    Copy of the order be made available to the parties as per rule.
File be consigned to record room.

    Announced in open sitting of the Forum on.....................