Order No.2

Ld. Advocate for the complainants is present.

The case is taken up for admission hearing.

Perused and considered the complaint application and annexures thereto,

Heard the Ld. Advocate for the complainants.

It is stated by the complainants that they availed a mediclaim policy from opposite party no.1 for the period 27/02/2017 to 26/02/2018. The complainant  no.2 had fallen ill and under advise of  doctor admitted in hospital on 24/11/2017 and undergone operation on the same date. She was discharged from the hospital on 27/11/2017. During her stay in the hospital a cashless facility was claimed by the complainants which was turned down by the opposite parties vide letter dated 27/1/2017. The complainant no.2 after discharge on 27/01/2023 from hospital submitted her claim with the opposite party no.1 on 20/12/2017. Till date, on one pretext or other the opposite parties have not settled the claim of the complainants yet.

According to the complainants, that they had hired insurance service for valuable consideration by paying adequate premium. The opposite parties are liable for deficiency in service for not settling the bonafide insurance claim of the complainant.

It is further stated that the cause of action arose on 25/11/2020 when the insurance ombudsmen passed its order inter alia dismissing the complaint of the complainants.

Ld. Advocate for the complainants referred an order of the Hon’ble Supreme Court of India passed in Writ Petition (c) No.3 of 2020 and submitted that the instant complaint petition is filed within the limitation period.

On scrutiny of the materials on record we find that cashless service facility was denied by the opposite parties vide letter dated 27/11/2017 i.e. the date on which the complainant no.1 was discharged from the hospital.

From the complaint application it appears that thereafter complainant no.2 filed her claim with the opposite party no.1 on 20/12/2017 for reimbursement of the amount which she spent for her treatment. It further appears from the record that the Insurance Ombudsman on 11/11/2020 passed an award against the complaint submitted by the complainant Vinod Kumar Sharma in his presence. The complaint was dismissed on 11/11/2020  without any relief to the complainant.

On careful scrutiny of the order of Insurance Ombudsman passed on 11/11/2020, we find that the complainant lodged a claim for Rs.4,38,843/- after getting discharged from the hospital but the insurance company repudiated the claim of the complainant no.2 as per exclusion clause 4.1 (pre existing disease).

Therefore, it is apparent from the document annexed by the complainants that their claim for reimbursement of the amount of treatment has already been repudiated by the opposite parties as per exclusion clause 4.1 but we find this fact has been suppressed by the complainants in their complaint application and repudiation letter issued by the opposite parties also not annexed with the complaint application. On the contrary, the complainants awarded in their application that their claim is yet to be settled by the opposite parties. In absence of the repudiation letter of the opposite parties we are unable to calculate the period of limitation in this case. Consequently Judgement of the Apex Court passed in Writ Petition mentioned above cannot be taken into consideration at this stage.

We have no hesitation to come to a conclusion that the complainants have not filed this case against the opposite parties with clean hands. in order to avoid the limitation, the complainants deliberately suppressed the fact of repudiation of their claim by the opposite parties in this case.

Having considered the discussion made above, we are of the opinion that the complaint case is not maintainable in law, as such, the same cannot be admitted and liable to be dismissed in limini.

Hence, it is

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that the complaint case be and the same is dismissed in limini as not maintainable.