C.K. Lekhamma, Member.

To put it shortly the facts leading to the complainant’s case are as follows :-

The complainant is a policy holder of the opposite party.  Complainant sustained severe bodily injuries due to an accident.  He was treated as inpatient from 7-12-2006 to 8-12-2006 at Nedumchallil Trust Hospital.  Muvattupuzha and spent Rs. 2,202/- towards treatment expenses.  Since no improvement was felt, he was admitted as inpatient at Nirmala Medical Centre, Muvattupuzha from 11-12-2006 to 20-12-2006.  He had to  spend Rs. 25,435/- towards treatment expenses.  Though two claims were submitted the opposite party allowed only the claim for Rs. 2,202/-.  Since no improvement was felt even after prolonged treatment he was referred from Nirmala Medical Centre to Ernakulam Medical Centre.  Complainant was treated there as inpatient from 22-4-2008 to 26-4-2008.  He underwent for a surgery also Rs. 1,33,164/- was spent towards treatment expenses.  Again a claim was submitted for Rs. 1,33,164/-.  But  it was repudiated by the opposite party on the ground that the claim is made after 6 months of the date of the alleged accident. The same is a violation of policy condition that the policy would cover readmission in the hospital only. According to the complainant reason  given for repudiation is not sustainable.  The readmission at Nirmala Medical Centre and Ernakulam Medical Centre was necessary and the same was mentioned in the medical certificate and discharge summaries issued by the respective hospitals.  And the  clause No. 7 of the policy conditions is applicable only in the case of weekly payment section. Therefore, this complaint is filed for getting following  reliefs against the opposite party. .  According to the complainant he is entitled for Rs. 25,435/- on the basis of the policy No. 101100/48/06/93/790 and Rs. One lakh being the sum insured on the basis of the Policy No. 101100/48/07/93/346 along with interest at the rate of 12% per annum till realization.  He is also entitled for Rs. 20,000/- towards compensation for the mental agony and hardships suffered by him due to the illegal repudiation of the claims.

2. The version filed by the opposite party is as follows:

According to the opposite party the policy was granted subject to its terms and conditions. The parties to the insurance contract are bound by the terms and conditions of the insurance policy.  The averment made in the complaint that the complainant is having the policy from 6-10-2004 is absolutely false.  The opposite party rightly repudiated the claim of the complainant.  As per the policy condition No. 7 the re-admission in the hospital has to be within 6 months from the date of accident whereas  in this case the insured re-admitted to the hospital after 2 years from the date of accident.  Thus the claim of the complainant clearly falls outside the scope of the policy conditions.  The contention raised by the complainant is that Clause No. 7 is applicable only in case of weekly payment section.  This is absolutely false and is against the scope of the policy.  The condition No. 7 specifying the weekly payment under which it is  payable and also specifying the period for re-admission in order to get the policy benefit.  The complainant had preferred a claim for Rs. 2,202/- and the said claim was settled by the opposite party.  Regarding the claim for Rs. 25,435/- the complainant had never lodged a claim with the opposite party.  Moreover nothing is adduced by the complainant in order to show that the said expenses was incurred for a treatment which arose out of an accident.  Moreover the case of the complainant that the said amount was spent for a treatment which was taken in December 2006, hence the said claim; is already time barred. The opposite party repudiated the claim of the complainant after considering all the relevant facts and in accordance with law relying on the policy conditions and the said action of the opposite party cannot be termed as a deficiency in service on their part and in the absence of deficiency in service on the part of the opposite party the complaint filed against them is not maintainable.

          3. The complainant and the  opposite party were appeared through the counsel.  Complainant examined as PW1 and Exts. A1 to A7 were marked on his side.  Only documentary evidence Ext. B1 was marked on the side of the opposite party.  Thereafter, evidence closed and heard both parties.

          4. Points for our determination are as follows:

          i. Whether the claim as per policy No. 101100/48/06/93/790 is barred by limitation.

          ii. Whether the complainant is entitled to get the medi claim on the basis of policy No. 101100/48/07/931/346?

          iii. Compensation and costs if any?

          5. Point No. I  According to the complainant he was treated as inpatient at Nirmala Medical Centre, Muvattupuzha from 11-12-2006 to 20-12-2006.   He spent Rs. 25,435/- towards treatment expenses.  Though the claim was submitted with the  opposite party, they advised  the complainant  to resubmit the claim after completion of the treatment.

          The opposite party denied the said contention of the complainant and averred that complainant had never lodged such a  claim with them in time .  Moreover the said that claim amount was spent for a treatment which he had  taken in December 2006, hence the claim is already time barred.

          Apart from the oral testimony of the complainant and Ext. A3 series photo copies of  claims  with respect to policy No. 101100/48/06/93/790 there is no other evidence before us to prove that  he had actually submitted the claim form before the opposite party with respect to the treatment at Nirmala  hospital, especially when the opposite party was vehemently disputed the submission of the claim application.  Ext. A3, the copy  of claim form is not sufficient to come a conclusion that he had actually submitted the same before the opposite party.  In the absence of any convincing, cogent and coherent  evidence we are of the view that the complainant failed to prove that he had submitted his  claim before opposite parties.  Therefore, the said claim of the complainant is time barred since it is of December 2006.

6. Points Nos. ii&iii. Regarding the claim in respect of the treatment at Medical Centre, Ernakulam, opposite party contented that the said claim of the complainant is hit under the policy condition No. 7.

          The relevant portion in clause No. 7 of Ext. B1 policy condition is as follows:

          The cover under weekly payment section would be provided only during the period of actual Hospitalization as Inpatient.  The Policy would cover re-admission in the hospital only if such re-admission is warranted and directly arising  out of the accident occurred to the insured, provided that the readmission into hospital is within 6 months from the date of accident.

          According to  the complainant is in Ext. A6 discharge summary, it is mentioned in the head “TREATMENT GIVEN” is that “He gives a history of RTA  (Road Traffic Accident) in December 2006”.

          As per the evidence it seems that the treatment at Medical Centre was in the  year  2008.  According to the complainant the treatment conducted at the Medical centre was in furtherance of the accident in 2006.  Complainant relied Ext.A6 discharge summary. Apart from the alleged cause of history - mentioned in Ext. A6 discharge summary, nothing is before us to prove that the present treatment is in consequence  of the alleged accident in 2006.  Seemingly, the complainant himself had narrated the history of accident in Ext. A6.  Hence we are of the considered view that Ext. A6 is not sufficient enough  to prove the complainant’s case. It is well

settled law that  Parties are bound by the terms and conditions of the agreement entered into. For the forgoing reasons we find no merit in this complaint  which is hereby dismissed without any order as to costs.                            

Pronounced in the open Forum on this the 29^th  day of July 2010