<br /> By Smt. Padmini Sudheesh, President: <br /> <br /> Petitioners’ case is as follows:<br /> <br /> Petitioner had taken a policy for his wife and children from the 2nd respondent and had also availed a mediclaim policy and had another accident policy. In order to avoid the complications the petitioner made enquiries regarding taking a new policy without losing the benefits of the previous policy. Then the petitioner renewed his policy with the first respondent without break vide policy No.760301/48/01/16631 from 18.2.02 to 17.2.03. Petitioner is continuing the policy and the premium amount is also duly remitted. Subsequently on 23.5.02 the wife of petitioner had undergone an operation for fibroid in uterus and incurred a total medical expenditure of Rs.19,239.74. Since there is valid policy the respondents are jointly and severally liable. The petitioner received a letter dated 19.3.03 from first respondent repudiating the claim. The petition filed before the Ombudsman was also dismissed on 21.6.04. The respondents have accepted premium for only one year of their mediclaim policy for which they are not providing almost any insurance coverage. The respondents are collecting high amount as premium. Therefore, this petition demanding the above e said amount and also compensation.<br /> <br /> 2. The version of first respondent in brief is as follows: The complaint is barred by limitation. This admits that they have issued a Hospitalisation and Domiciliary Hospitalisation Benefit Policy to the complainant, his wife and two children as per policy No.7604301/48/01/16631 for Rs.25000/- each. The policy was effected from 18.2.2002 to 17.2.2003 subject to the terms, conditions, exception and limitation stipulated therein. In this complaint the prayer for reimburse the medical expenses incurred by the wife of the complainant for her alleged treatment. The complainants wife is also an insured under the policy. Since she is not a party in the proceedings the complaint is bad for misjoinder of necessary parties. The petitioner can renew his policy with first respondent without losing his benefits of the previous policy with the 2nd respondent is false and denied. This respondent has not renewed any policy issued by the 2nd respondent in connection with the claim in the complaint. This respondent has not renewed any policy issued by the 2nd respondent in connection with the claim in the complaint. This respondent has issued an independent policy with independent terms, it has no connection with the alleged policy issued by the 2nd respondent. The allegation that “the respondents are collecting high amount as premium” is not correct. Since the claim of the petitioner comes under the first year exclusion 4.0 and 4.3 of policy availed by insured, claim was repudiated and letter sent. After the repudiation of the claim by the petitioner, he has approached the Insurance Ombudsman and the complaint was dismissed. The claim amount is highly excessive. The claim is not in accordance with the policy. Hence dismiss.<br /> <br /> 3. The 2nd respondent has filed counter to the effect that the 2nd respondent has not issued any policy to the petitioner covering the risk of the petitioner’s wife for the treatment undergone in May 2002. There is no privity of contract between this respondent and petitioner. Hence the respondent may be exonerated from the liability. <br /> <br /> 4. The points for consideration are:<br /> <br /> (1) Whether the petition is barred by limitation?<br /> (2) Whether the petitioner is entitled to get the policy benefit?<br /> (3) Reliefs and costs. <br /> <br /> 5. The evidence consists of Ext. P1 to P12 and R1 to R10. No other evidence.<br /> <br /> 6. Point No.1: The first point to be considered is whether the petition is barred by limitation. IA-438/06 has filed by the complainant to condone a delay of 58 days. According to the complainant, the time was lost by approaching the Ombudsman and there is only a delay of 58 days. Going through the averments, it can be seen that the delay is not willfully. Hence IA-438/06 allowed and this point is found in favour of the complainant.<br /> <br /> 7. Points-2 & 3: The second point to be decided is concerning the policy benefits. According to the petitioner, he has renewed the policy with first respondent, which existed with 2nd respondent from 18.2.02 to 17.2.03. He is continuing the policy and the premium is also duly remitted. This is not true. This is not the renewal of policy; it is a new policy with New India Assurance Company and having independent conditions, terms and exclusions. The case of the petitioner is that during May 2002, the wife of the petitioner had some problems in uterus and has admitted in Amala Hospital, Thrissur and had undergone an operation due to Fibroid in uterus on 23.5.02. That is within the policy period and she is entitled to get the policy benefits. The first respondent contended that as per Clause 4.3 of the policy, which is marked as Ext. R10 during the first year of the operation of the insurance cover the expenses of treatment of some diseases including Hysterectomy for Fibromyoma. The insurer pointed out that under the exclusions of Clause 4.2 and 4.3 the claim was repudiated. Taking of policy is only to obtain financial assistance under the policy. At the time of joining the policy there is no mandate for medical check up. If medical check up was done, there is chance to find out the said disease and the petitioner and his family may be waived from joining the policy. Moreover, petitioner was under the impression that this policy is renewal of the existing policy with 2nd respondent United India Insurance Company. The claim put forward by the petitioner is genuine. Repudiation of a genuine claim after receiving the premium is unfair and unjust. Hence the petitioner is found to get the policy benefits from the first respondent. <br /> <br /> 8. In the result, petition is allowed and the first respondent the New India Assurance Company is directed to provide Rs.19,239/- (Rupees nineteen thousand two hundred and thirty nine only) to the petitioner with interest at the rate of 12% per annum from June 2002 and 6% interest from today till realization. The first respondent is further directed to give Rs.1000/- (Rupees one thousand only) towards costs. Time for compliance one month. <br /> <br /> <br /> Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum, this the 11th day of July 2008.<br />