By Jayasree Kallat, Member: The petition is filed by Mr. Satheesh alleging deficiency of service on the part of opposite parties. The petitioner had taken a policy numbered as 761301/48/05/20/70050163 from the first opposite party on 21-2-06. The policy was for hospitalization and domiciliary hospitalization benefit. The complainant, complainant’s wife and daughter came under the policy, for an amount of Rs.50000/- each as sum assured. Duration of the policy was from 21-2-06 to 20-2-07. The complainant’s wife had bleeding and severe pain during the month of May 2006, for which she consulted Dr. Nisha Mukundan at Baby Memorial Hospital. Complainant’s wife was advised to consult a Dr. Ajitha, Gynecologist of the same hospital. On 19-5-06 the complainant had undergone a Total Laproscopic Hysterectomy Indicating Multiple Fibroids. She was discharged on 20-5-06. Complainant had to expend an amount of Rs.41740/- towards the surgery of his wife. Complainant preferred a claim before opposite party-1 claiming the amount expended towards the treatment of his wife. On 13-6-06 opposite party intimated the complainant repudiating the claim. Complainant sent a Lawyer notice to the opposite party for which opposite party has not given any explanation or given the claim amount as per the policy. This petition is filed alleging negligence and deficiency on the part of opposite parties for not disbursing the claim amount on time. Opposite party-1 filed a version denying the allegations and averments in the complaint except those that are expressly admitted. First opposite party admits issuing the policy to the complainant, his wife and daughter for Rs.50000/- each as sum insured for the period of 21-2-06 to 20-2-07. As per the exclusion clause No.4.3 contained in the policy the company shall not be liable to make payment under the policy towards any expenses incurred by any insured person during the first year of operation of insurance cover on treatment of disease Hysterectomy for Menorrahagia or Fibromyoma. The disease of complainant’s wife was under the exclusion clause No.4.3 of policy. Opposite party had no other option than to repudiate the claim. The opposite party is not liable to pay the claim amount to the complainant. There is no deficiency on the part of opposite party. Opposite party prays to dismiss the petition. Opposite party-2 also filed the version denying the allegations in the complaint. Opposite party-2 admits that the claim was preferred by the complainant for getting benefits under the Hospitalisation ad Domiciliary Hospitalisation benefit under the insurance policy. As per the exclusion clause No.4.3 in the policy issued to the complainant, the insured is not entitled to get expense on treatment of disease like hysterectomy for menorrahagia or fibromyoma during the first year of the operation of the insurance. The claim of the complainant was for the expense for the treatment of hysterectomy during the first year of operation of the insurance cover. The opposite party had no other option than to repudiate the claim of the complainant. There was no deficiency on the part of opposite party. Opposite party prays to dismiss the complaint with costs to the opposite party. The only point for consideration is whether the complainant is entitled to get any relief? PW1 was examined and Ext.A1 to A4 were marked on complainant’s side. RW1 was examined and Ext.B1 to B3 were marked on opposite parties’ side. According to the complainant the complainant had taken an insurance policy for himself, his wife and daughter for an amount of Rs.50000/- each as sum insured on 21-2-06. His wife had to undergo hysterectomy on May 2006 at Baby Memorial Hospital. Complainant had preferred a claim before the opposite party claiming the amount expended towards treatment of his wife. Opposite party repudiated the claim stating that the claim cannot be allowed as per the policy conditions. Ext.B2 produced by the opposite party shows that as per clause No.4.3 of the medi claim insurance policy complainant is not entitled for the claim amount. According to Clause No.4.3 of the policy during the first year of the operation of insurance cover the expenses on treatment such as hysterectomy for menorrahagia or Fibromyoma are not payable. Ext.A1 shows that the complainant had taken the policy on 21-2-06 which would extend upto 20-2-07 complainant’s wife had undergone surgery after three months of taking the policy. As per the policy conditions Clause No.4.3 during the first year of operation of insurance cover the expenses on treatment of disease such as hysterectomy for menorrahagia or Fibromyoma is not payable. Ext.A3 discharge summary from Baby Memorial Hospital shows that complainant’s wife Ranjini had undergone surgery Total Laproscopic Hysterectomy Indicating Multiple Fibroids. Surgery was done on 19-5-06. The complainant had taken insurance policy on 21-2-06. The surgery was conducting during the first year of operation of the insurance cover. In this circumstance we are of the opinion that as per insurance policy condition clause No.4.3 the complainant’s wife is not entitled for the claim amount. In the result the petition is dismissed. Pronounced in the open court this the 5th day of February 2010. Sd/- PRESIDENT Sd/- MEMBER Sd/- MEMBER APPENDIX Documents exhibited for the complainant. A1. Photocopy of Mediclaim Insurance Policy. A2. Photcopy of Medical Certificate (Attenting Doctyors Report) A3. Discharge Summary from Baby Memorial Hospital, Calicut. A4. Photocopy of Medical bills ( 14 in Nos.) Documents exhibited for the opposite parties. B1. Copy of Policy. B2. Mediclaim Insurance Policy. B3. Copy of Lawyer notice dt. 2-11-2006. Witness examined for the complainant.: PW1. Ranjini Satheesh, Keloth, Shravana, Near S.N.H.S.S. Vatakara. Witness examined for the opposite party. RW1. Viswanathan, Administrative Officer of 1st O.P. Sd/- President // True copy // (Forwarded/By order) SENIOR SUPERINTENDENT.
......................G Yadunadhan
......................Jayasree Kallat
......................L Jyothikumar | | 
