DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi- 110016
Case No.623/10
Shri Shivanand Banam
S/o Shri Sheena Banam
B-115, 3rd Floor, Malviya Nagar
New Delhi-110017. …Complainant
VERSUS
National Insurance Co. Ltd.
Through Divisional Manager
C-6, Gurdwara Road
NDSE-I
New Delhi-110019. …Opposite Party
Coram:
Ms. Monika A Srivastava, President
Ms. Kiran Kaushal, Member
Sh. U.K. Tyagi, Member
ORDER
Date of Institution : 05.10.2010
Date of Order : 28.02.2023
Ms. Monika A Srivastava, President
The complainant has filed the present complaint seeking Rs.61,987/- as expenses incurred by the complainant for medical treatment along with interest @12% per annum, a sum or Rs.50,000/- for mental injury and harassment and Rs.10,000/- as cost of litigation.
- The complainant has filed a present complaint which obtained a hospitalisation and domiciliary hospitalisation benefit Policy which a credit mediclaim policy being master policy No.350700/46/02/8500119 for a sum of Rs.2 Lakhs for the period 2003-2004 the said policy was renewed till 2010-2011 for a consideration of Rs.5032/-. Copy of the policies annexed as Annexure-C-1. The said policy was issued for the entire family consisting of the complainant, his wife and his two sons. It is stated by the complainant that during the subsistence of the policy the complainant fell seriously ill and was admitted to Healing Touch Hospital on 04.10.2009 with complaint of severe abdominal pain, vomiting and difficulty in passing urine. After a few days of treatment complainant was detected as being suffering from stone disease. Complainant was discharged on 09.10.2009. Thereafter, he was taking medicines and rest according to the direction given by the doctors. Copy of the medical reports are annexed as annexure C-2.
- It is stated by complainant that he incurred expenses of Rs.61,987/- on his illness and claimed insurance benefit from the OP. However, he did not get any response from the OP and he has sent two legal notices to OP dated 11.05.2010 and 08.06.2010. Copies of the same are annexed as Annexure-4.
- The OP filed their reply dated 25.06.2010 repudiated the claim of the complainant as alleged on frivolous, baseless and non-existence grounds. Copy of the reply dated 25.06.2010 is annexed as Annexure C-5.
- It is stated by the complainant that terms and conditions of the policy were not furnished to the complainant at the time of obtaining the policy and only the cover note of the policy was issued and it was promised that the detailed policy will be sent through post.
- It is stated by the complainant that OP has deputed unfair trade practice and repudiated the claim of the complaint without any substantial material or proof which amount to deficiency of service and unfair trade practice.
- In their reply the OP has stated that the complaint involves disputed question of facts adjudication of which requires recording of detailed oral and documentary evidence and therefore should be triable by a civil court.
- The OP has also stated that the complaint is an afterthought and has been filed with the malafide intention to cause financial losses and to extort money from the OP. Though it deserves to be dismissed being devoid of merits.
- It is stated by the OP that complainant was initially covered under the group mediclaim policy which was issued by Oriental Insurance Company and the complainant took the Parivar Mediclaim Policy from OP i.e. National Insurance Company commencing from 20.03.2008 for a period of one year which was subsequently renewed on 20.03.2009.
- It is further stated that the Mediclaim Policy was issued subject to terms and conditions which are binding on both the parties and at no point of time the OP can go beyond the scope of the terms and conditions of the policy.
- It is further stated that in the present case the claim of the complainant was for treatment of stones and the same was denied on account of non-coverage as per Clause 4.3 which reads as under:-
“4.3 During the First two years of the operation of insurance Policy, the expenses on the treatment of diseases such as cataract, Benign Prostatic Hypertrophy. Hysterectomy, Hernia, Hysrocoele, Internal Congenital Defects/Diseases or anamalies. Fistula in Anus, Piles, Chronic Fissure in Anus. Pilonidal Sinus. Sinusitis, Stone disease of any size, Benign umps/growths in any part of the body, CSOM (Chronic Suppurative Otitis Media) Joint Replacement of any kind unless arising out of accident, surgical treatment of Tonsils and Adenoids, Deviated Nasal Septum and Chronic Disease are not payable, if these diseases are pre-existing at the time of proposal, they will not be covered even during subsequent period of renewal too.”
A copy of the terms and conditions of the policy is attached and annexed herewith as Annexure-1.
- Since the policy was taken for the first time in the year 2008 and the claim was filed within first two years of the commencement of the policy therefore the case of the complainant fell under the exclusion Clause 4.3 and was not payable.
- The OP has denied that the terms and conditions of the policy were not furnished to the complainant at the time of providing policy and a copy of the letter dated 25.06.2010 is reproduced:-
“We are also send herewith the terms and conditions of the Parivar Mediclaim Policy for ready reference….”.
- It is further submitted by the OP that it is the custodian of the public money at large and is under statutory as well moral obligation to reimburse the claims after due scrutiny therefore in the present case the claim of the complainant was rejected having regard to the exclusion Clause 4.3.
Both the complainant as well as the OP have filed their respective evidence affidavits as well as written arguments. This Commission has gone through the entire material on record and it is seen from the document filed on record by the complainant with the policy which was in effect in 2003-004 was issued by the OP, however, later on, 2006-2007 onwards the policy was issued by Oritental Insurance Company and thereafter again in 2008-209 and 2009-2010 issued by the OP. This Commission has also seen the Clause 4.3 which states that stone disease of any size would not be covered during the first two years of the operation of Insurance Policy. Therefore, this Commission is of the view that the claim of the complainant has been rightly repudiated and the complaint is without any merits. Complaint is dismissed.
File be consigned to the record room after giving copy of the order to the parties. Order be uploaded on the website.
