ORDER
NIPUR CHANDNA, MEMBER
Complainant is a mediclaim policy holder of OP Company vide policy no. 360700/48/11/8500000460 w.e.f. 26-4-2011 to 25-4-2012. It is alleged by the complainant that his wife was admitted on 13-8-2011 in Sujan Mohinder Hospital for an emergency operation relating to abdominal hernia and discharged on 16-8-2011.
It is further alleged by the complainant that he had submitted the claim documents to OP3 on 12-10-2011 as he had gone to Kolkata because his mother was hospitalized due to severe kidney ailments and she expired on 16-9-2011. It is further alleged by the complainant that the OP2 asked them to explain the delay in inimation of claim to it. The complainant again communicated to the OP that he had disclosed reason for delay vide letter dated 12-10-2011.
It is alleged by the complainant that even after receiving the explanation of delay in intimation of the claim, the OP company had closed his claim file on false and flimsy ground. Hence, this complaint.
OP insurance company has contested the complaint and filed written statement. Para no. 2 of the preliminary objection of written statement filed by OP1 is relevant and the same is reproduced as under:
2.That theabovesaid'complaint is not maintainable as there is no deficiency in the service on the part of the Opposite Party/Insurance Co. The Complainant has not timely intimated the answering Respondent about his claim and has been deliberately delayed in lodging of his claim with the answering Respondent. Hence, the claim file of the Complainant was closed, as the same was not filed as per the terms and conditions of the mediclaim policy, provided to the
Complainant.
Both the parties have filed their evidence by way of affidavits.
We have heard arguments advanced at the bar and have perused the record.
While hearing the arguments and perusal of record, it was found that the OP insurance company had rejected the claim of the complainant merely on the ground of delay in lodging the claim. Vide order dated 3.3.2015 the Op insurance company was directed to re-process the claim of the complainant as there are instructors / guidelines of the IRDA that a claim cannot be rejected only on the ground that there has been a delay in lodging claim.
As per the order dated 3-3-2015 the OP company had reprocessed the claim and submitted its report and again repudiated the claim of the complainant vide letter dated 10.7.2015 with the reason that “ The claim is not admissible as per the policy exclusion clause no. 4.1 and 4.3.
Again we have heard the argument of both the parties on the report filed by the OP company. The counsel for the OP has contended that the wife of the complainant was suffering from incisional hernia, and as the policy was running into 2nd year , the same is excluded under clause 4.1 and 4.3 of the policy, and as such the OP company had rightly repudiated the clam of the complainant.
He has placed on record the opinion dated 9-7-2015 of the panel doctor Sh. Vinod Gandohtra in support of his contention.
The following lines of the report dated 9.7.2015 is relevant for the disposal of this case:-
“This is case of hospitalization , for the surgical management of Incisional Hernia (Obstructed). It is well supported with the operation findings, stated in the discharge summary of Sujan Mohinder Hospital.
This is a 2nd year of Mediclaim Coverage, as covered since 26.4.2010 onward, thus claim is not tenable under the purview of the policy and can be repudiated as per terms and conditions of individual mediclaim policy on the ground of :-
- Exclusion Clause no. 4.1 as Insciional hernia word is self explanatory that one has earlier surgery, in the past and from that previous scar mark, the said hernia , is developed. It is well supported with the operation findings.
- Exclusion clause no. 4.3.”
We are in agreement with the contention of the counsel for the OP. The Operative findings of the discharge summary dated 16.8.2011 also makes it clear that the wife of the complainant was suffering from “Incisional Hernia” which falls under the ambit of exclusions clause 4.1 and 4.3 of the policy.
“ In the case of United India Insurance Co. Ltd. vs. Harchand Rai Chandan Lal (2005 ACJ 570), the Hon’ble Supreme Court has held that the terms and conditions of the contract have to be strictly construed and no variation can be made there from.”
In view of the judgment cited by us above and facts and circumstances of the case, we are contrained to hold that the OP had righlty repudiated the claim of the complainant. We , therefore, see no deficiency in service on the part of the OP.
Accordingly compljaint 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.....................
