By Smt. Padmini Sudheesh, President<br /> <br /> The case of the petitioner is as follows:<br /> <br /> Petitioner was a holder of Jeevan Raksha Insurance Policy vide policy No.570704/47/2000/9600863. The sum assured for accident was Rs.25,000/- and the validity period was from 7/3/01 to 6/3/06. As per the conditions of the policy the petitioner is eligible to get refund of medical expenses incurred for the treatment of injury sustained due to accident as impatient in a hospital or nursing home in India each year. During the policy period the petitioner had accidental fall in her home on 6.6.01 and sustained fracture and admitted in Amala Hospital, Thrissur. After necessary treatment she was allowed to return to her house with a direction to visit again whenever any problem occurs. On 21.6.01 the petitioner again met the doctor with some ailments connected with the said fracture and admitted and discharged on the next day. After this she consulted a consultant Orthopedic Surgeon at Ernakulam and subsequently consulted another specialist doctor at Coimbatore. On the advice of this doctor she had admitted in the United Apollo Hospital, Coimbatore. On 5.12.01 surgery was done and discharged on 11.12.01. She then preferred a claim with first respondent for reimbursement of Rs.4415/- as incurred for treatment at Amala Hospital. The first respondent paid Rs.3150/- against that claim. In January 2002 she had preferred another claim for Rs.37,562/- towards expenses incurred at United Apollo Hospital, Coimbatore. But the respondents repudiated on the ground that the treatment was for a pre-existing disease. Aggrieved by this, the petitioner filed a complaint before the Grievance Cell of respondents functioning at Ernakulam which was also repudiated. She then filed a complaint before the Insurance Ombudsman and rejected the complaint and found in favour of the respondents. Hence this Complaint.<br /> <br /> 2. The counter of the respondent is as follows: This complaint is barred by resjudicata and law of limitation. The complainant had filed a complaint before the Ombudsman and dismissed on merit. This respondent repudiated the claim on 4.10.02 and the complainant filed this complaint only on 16.3.05 thereby barred by limitation and no reason stated to condone the delay. The respondent admitted that the petitioner is a policyholder and the policy is valid from 7.3.01 to 6.3.06 subject to terms and conditions. As per mediclaim insurance policy exclusions, the company is not liable to make any payment because the disease is pre-existing. More over as per policy conditions suppression of material facts renders the contract of insurance void. The petitioner was well aware of these conditions at the time of availing insurance coverage. Since the first claim was only for a nominal sum, no investigation held in respect of it. But the second claim for Rs.37,562/- the discharge summary for the treatment at Coimbatore necessitates the investigation. Hence dismiss the complaint. <br /> <br /> 3. The points for consideration are:<br /> <br /> (1) Whether the complaint is barred by limitation?<br /> (2) Whether the complaint is hit by the principles of resjudicata?<br /> (3) Whether the petitioner is entitled for the insurance claim?<br /> (4) Whether the petitioner is entitled to get compensation as prayed?<br /> (5) Reliefs and costs.<br /> <br /> 4. The evidence consists of Exts. P1 to P10 and Exts. R1 to R12.<br /> <br /> 5. The first point to be considered is regarding the limitation period. As per the complaint and counter it can be seen that the repudiation of the claim was on 4.10.02. This complaint has filed only on 16.3.05. There was a delay of five months. As per Section 24A(1) of the Consumer Protection Act, the Forum shall not admit a complaint unless it is filed within two years from the date on which the cause of action has arisen. Sub Section (2) made it clear that, a complaint may be entertained after the said period, if the complainant satisfies this Forum that he had sufficient cause for not filing the complaint within such period. Here the petitioner had not taken steps to condone the delay caused. This is a prima facie defect and the petition is liable to be dismissed only on this ground without going to the other facts.<br /> <br /> 6. In the result, the petition is dismissed. No order as to costs.<br /> <br /> <br /> Dictated to the Confidential. Assistant, transcribed by her, corrected by me and pronounced in the open forum this the 18th day of June 2008.<br /> <br />