ORDER

Complaint under  Sec.12 of the CPA 1986 as amended upto date

Ms. Nipur Chandna, Member

          Complainant is the mediclaim policy holder of the OP company vide policy No. 35020/48/13/8500000234  w.e.f. 9.4.2013 to 8.4.2014.

         It is alleged by the complainant that his son was admitted in Max Super Speciality Hospital for the treatment of Dengue and was discharged on 15.5.2013.

           It is further alleged by the complainant that he had submitted all original documents as required by the OP company but inspite of it, OP company did not make any payment t him, and vide letter dated 16.7.2013 closed his claim file as “No Claim”.

         It is alleged by the complainant that he had sent a legal cum demand notice to the OP but no response was given by the OP .  Hence, this complaint.

          Complaint has been contested by the OP.  Para No. 3 of the W.S. filed by the OP company is relevant and is reproduced as under:-

 Para No. 3

 That as per the opinion of the TPA on the panel of the answering opposite party and the documents submitted by the complainant, the claim of the complainant was found not admissible as per clause 4.2 of the terms and conditions of the insurance policy according to which the claim has taken place within first 30 days from the day of inception of the policy.  On verification of IPD records of patient Master Ansh Gupta it has been observed that the patient first time consulted doctor for the disease on 7.5.2013.  The patient is covered under the Pariwar Mediclaim policy since 9.4.2013.   As such this claim has taken place within first 30days from the day of inception of the insurance policy.  Hence, the answering opposite party has rightly repudiated the claim and there is no deficiency in service on it’s part.  Copy of Insurance Policy along with terms and conditions of the insurance policy is annexed herewith as annexure ”A”.  Copy of report of TPA are annexed herewith as annexure B.  Copy of treatment documents dated 7.5.2013 is annexed herewith as annexure C.

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

     The counsel for the OP has contended that the policy in question is the first year policy w.e.f. 9.4.2013 – 8.4.2014 and the complainant has filed the claim within 30 days of the policy i.e. the son of the complainant was admitted on 9.5.2013, and as such the case of the complainant falls under exclusion clause no. 4.2 of the policy terms and condition.

      The counsel for the OP has further contended that as the claim of the complainant is not tenable as per exclusion clause no. 4.2 of the policy, hence the OP company had rightly closed the claim file of the complainant as no claim.

     The counsel for the OP has drawn our attention toward exclusion clause no. 4.2 of the policy which reads as under:-

     Any disease other than those stated in Clause 4.3 contracted by the Insured Person during the first 30 days from the commencement date of the policy.  This condition 4.2 shall not however, apply in case hospitalization due to accidental injury or if the Insured Person having been covered under this scheme or a similar Health Insurance Scheme with any of the Indian Insurance Companies for a continuous period of preceding 12 months without any break and has prayed for dismissal of complaint.

A perusal of above clause in the terms and conditions of the policy shows that any claim on treatment taken by the insured/beneficiary within 30 days of the inception of the policy is not payable.

  In the present case the policy was purchased on 9.4.2013 and the son of the complainant was admitted for treatment on 9.5.2013 which is within 30 days of the inception of the policy.

We are therefore, of the considerable opinion that the OP had rightly repudiated the claim lodged by the complainant as it was not payable under undo terms and condition of the policy purchased by the complainant.

     In the light of above discussion we find no merits in the complaint.  The same is hereby dismissed

            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.....................