BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.190 of 2015

Date of Instt. 06.05.2015

Date of Decision :08.10.2015

Smt.Pushpa Devi aged about 62 years son of Krishan lal R/o H.No.7/12, Mohalla No.17, Hardyal Road, Jalandhar Cantt.

..........Complainant Versus

1. National Insurance Company Limited, 89, Mahavir Marg, BMC Chowk, Jalandhar through its Branch Manager.

2. Raksha TPA Pvt Ltd, 2nd Floor, SCO-181, Sector-7-C, Chandigarh.

.........Opposite parties.

Complaint Under Section 12 of the Consumer Protection Act.

Before: S. Jaspal Singh Bhatia (President)

Ms. Jyotsna Thatai (Member)

Present: Sh.Nitin Gupta Adv., counsel for complainant.

Sh.Darshan Singh Adv., counsel for opposite parties.

Order

J.S.Bhatia (President)

1. The complainant has filed the present complaint under section 12 of Consumer Protection Act, against the opposite parties on the averments that the complainant was approached by the opposite parties for giving her cover of family medical insurance policy. The opposite parties after acceptance of insurance premium, issued the insurance policy for the period from 12.2.2013 to 11.2.2014 and from 12.2.2014 to 11.2.2015 vide No.401104/48/13/ 8500000404. All of sudden the complainant has suffered some problems and was admitted in Chitra Hospital, Mohalla No.8, Jalandhar Cantt on 27.8.2014. The attending doctor operated the complainant. At the time of discharge, the complainant paid the hospital bill of Rs.40,815/- which is duly covered under the insurance policy. Thereafter paying the above said amount, the complainant applied to the opposite party No.1 for the claim the above said amount of Rs.40815/- and submitted all the documents to the opposite party No.1. The opposite party No.1 had forwarded the claim of the complainant to the opposite party No.2. The opposite party No.2 has demanded documents from the opposite party No.1 for insurance claim and the opposite party No.1 has submitted these documents to opposite party No.2 on 16.1.2015. The opposite parties till date has not made the payment of claim amount to the complainant without any sufficient cause and reason and are lingering on the matter on one pretext or other. The agent of opposite parties has received the premium of insurance policy again on 6.2.2015 for the period 12.2.2015 to 11.2.2016 on the pretext that their claim has been passed and cheque of the claim shall be delivered to the complainant shortly and the opposite parties has also issued policy No.401104/48/14/ 8500000371 to the complainant. But till date the opposite parties have not given the claim amount to the complainant. The complainant also served a legal notice dated 23.3.2015 through his counsel to the opposite parties calling them to pay amount of Rs.40815/-(alongwith interest 18% per annum) for medical claim and further the opposite parties are liable to pay Rs.50,000/- as damages or amount of compensation on account of mental tension, harassment and agony but the opposite parties has given false reply to the legal notice and rejected the claim of the complainant. On such like averments, the complainant has prayed for directing the opposite parties to pay her the claim amount of Rs.40850/- alongwith interest. She has also claimed compensation and litigation expenses.

2. Upon notice, opposite parties appeared and filed a written reply, inter-alia, pleading that complainant was informed through registered letter by the opposite parties in reply to her legal notice, they have already closed the claim file as "No Claim" as claim falls under the first two years exclusion clause of the policy. They denied other material averments of the complainant.

3. In support of her complaint, learned counsel for the complainant has tendered into evidence affidavit Ex.CA alongwith copies of documents Ex.C1 to Ex.C11 and closed evidence.

4. On the other hand, learned counsel for the opposite parties has tendered affidavits Ex.OPA alongwith copies of documents Ex.OP1 to Ex.OP8 and closed evidence.

5. We have carefully gone through the record and also heard the learned counsels for the parties.

6. The fact that complainant had obtained mediclaim policy is not disputed. Counsel for the complainant contended that the complainant all of a sudden suffered some problem and was admitted in Chitra Hospital, Jalandhar on 27.08.2014 and was operated upon and at the time of discharge, she has paid hospital bill of Rs.40815/- which is fully covered under the insurance policy but opposite party has wrongly rejected the claim of the complainant on the ground that the claim falls under first two years exclusion clause or waiting period. He further contended that the terms and conditions of the policy were also not supplied to the complainant. We have carefully considered the above contentions advanced by learned counsel for the complainant. In the complaint, the complainant has no where pleaded that terms and conditions of the policy were not supplied to her. Moreover, the complainant had obtained the policy firstly from 12.2.2013 to 11.2.2014 and for second time w.e.f. 12.2.2014 to 11.2.2015. So before the policy in question, she had also obtained policy for the previous year. It is not shown if the complainant ever wrote any letter to the opposite party insurance company demanding terms and conditions of the policy before she was admitted in the hospital. So this version of the complainant can not be accepted. Moreover, the complainant has not alleged in the complaint that she did not receive the terms and conditions of the policy. The opposite party has produced the terms and conditions of the policy which are attached with policy Ex.OP1. As per condition/clause 4.3 of the terms and conditions of the policy, there is specific waiting period provided as under:-

"4.3 Specific waiting period.

Following disease/treatments are subject to a waiting period mentioned below:-

i. One year waiting period

a. Benign ENT Disorders

b. Surgeries like Tonsillectomy/Adeniodectomy/ Mastiodectomy/Tympanoplasty.

ii. two years waiting period.

a. Cataract k. Pilonidal sinus

b. Benign prostatic hypertrophy l. Gout and Rhenumatism

c. Hernia m. Hypertension and related complications

d. Hydrocele n. Diabetes and related complications

e. Congenital internal disease o. Calculus diseases

f. Fissure/Fistula in anus p. Surgery of gall bladder and bile duct excluding malignancy

g. Piles(Haemorrhoids) q. Surgery of genito0urinary system excluding malignancy

h. Sinusitis and related disorders r. Surgery for prolapsed inter vertebral disc unless arising from accident.

i. Polycystic ovarian disease s. Surgery of varicose vein

j. Non-infective arthritis t. Hysterectomy.

7. So as per claue 4.3 (ii) (q) or 4.3 (ii) (t) there is a waiting period of two years. Ex.O7 is discharge slip of the complainant and in the discharge slip diagnosis of the complainant is mentioned as Adenomyosis ut c irregular heavy bleeding. Further from the operation notes given on the discharge slip it is evident that the surgery was performed and uterus of the complainant was removed. So the disease for which the complainant was operated upon falls under clause 4.3 (ii) (q) or 4.3(ii) (t). In both cases the waiting period is of two years. Hysterectomy is removal of uterus by way of surgery. So the case of the complainant falls under 4.3 (ii) (q) or 4.3(ii) (t) and as already observed above in both the cases, there is a waiting period of two years. Admittedly, the complainant had not completed the waiting period of two years before under going the above said surgery. So the opposite party insurance company has rightly repudiated her claim.

8. In view of above discussion, we hold that there is no merit in the present complaint and same is hereby dismissed with no order as to cost. Copies of the order be sent to the parties free of costs under rules. File be consigned to the record room.

Dated Jyotsna Thatai Jaspal Singh Bhatia

08.10.2015 Member President