| Final Order / Judgement | Order below on Exh.1 - Heard argument of the Complainant at the stage of the admission of the case; perused the record of the complaint with all the documents.
- The Complainant has taken insurance policy no.330203341995500000160 for the period 05/09/2020 to 04/09/2021 from the Respondents. The Complainant and his wife were covered under the said policy.
- Since past few years the insured was experiencing sleeping and breathing issues, for which they took advise and medication from various Doctors.
- On 23/09/2019 Cytology study was conducted on the insured. Doctors and medical experts were advising that, to take advise and diagnosis from the ENT specialist.
- Therefore, he met Dr.Rishabh Jain at Siddham ENT Center. After examining the insured and her medical history, the said doctor advised for NCCT scan of PNS. The said test was done on 28/11/2019.
- Meanwhile the Complainant’s wife health condition was deteriorated and became critical. She was having difficulty in breathing and swallowing.
- Therefore, Dr. Rishabh Jain advised to the Complainant that immediate surgery would require, hence, it was decided to carry out the surgery in the month of December after marriage of their son.
- On 17/12/2019 the condition of Complainant’ wife had become worst. Hence admitted on 19/12/2019 at Siddham ENT Center for surgery. On 20/12/2019 surgery was conducted on 20/09/2019 and discharged on 23/12/2019.
- Thereafter due to some complications Complainant’s wife was again admitted on 31/12/2019 and was discharged on 04/01/2020.
- Therefore, the claim was lodged with Respondent for Rs.1,84,742/-.
- On 21/07/2020 the said claim was repudiated by the Respondent as per the clause 4.4.23 treatment related sleep apnea is not covered under the subject policy.
- Hence, the Complainant has raised grievance against rejection of claim to the Regional Manager, Grievance Cell through letter dt.18/09/2020. On 21/12/2020 the Respondent has informed to the Complainant that; the claim is not payable as per observation of the panel Doctors.
- On 17/08/2021 the Complainant has issued letter to the grievance cell for to review the decision of the rejected claim; but in vain. The Complainant tried seeking documents of the proceeding of claim, but the Respondent company did not supply the documents. Therefore, the Complainant was constrained to file RTI application to get all the documents. Hence, the Respondent has provided opinion letter dt.10/12/2020 of Dr.Kamal Jain who is panel doctor. Thus, the Complainant is not satisfied with Respondent and their panel doctor’s view. Therefore, he has been constrained to file present complaint with following prayers:
- Direct the Respondent to pay insurance claim of Rs.1,84,742/-
- to pay compensation of Rs.4,00,000/- towards mental agony
- to pay Rs.1,00,000/- towards negligence performing its duties
- to pay Rs.50,000/- towards costs of litigation
- to pay Rs.25,00,000/- under provision of Sec.21read with Sec.88 of the C P Act,2019
- to pay 12%p.a on total sum
- The Complainant has placed reliance on true copies of following documents:
- Policy certificate
- Claim rejection letter dt.21/07/2020
- Discharge summary dt.23/12/2019
- Copy clam amount
- Respondent’s letter dt.21/12/2020
- Grievance letter dt.18/09/2020 by Complainant
- Grievance letter dt.17/08/2021 by Complainant
- RTI application
- Considering the contention and the argument of the Complainant, the following point arises for our determination.
| | Whether the present case is barred by limitation? | .... Yes.... | What order? | As per final order..... |
- The Complainant has taken insurance policy no. 330203341995500000160 for the period 05/09/2020 to 04/09/2021 from the Respondents. The Complainant and his wife were covered under the said policy.
- The Complainant’s wife was admitted on 19/12/2019 at Siddham Hospital and was operated on 20/12/2019 for ENT Surgery. On 23/12/2019 after completing post surgery procedure she was discharged on 23/12/2019. Due to some complications she was again admitted on 31/12/2019 and was discharged on 04/01/2020.
- Thereafter the Complainant has lodged the medi-claim with Respondent. On 21/07/2020 the Respondent repudiated claim as per clause 4.4.23 that treatment related sleep apnea are not covered under the policy.
- Therefore, the first cause of action was arisen to the Complainant, when the Respondent rejected the insurance claim i.e. on 21/07/2020. Thus, from 21/07/2020 the case should have been filed within two years i.e. till 21/07/2022; but the present case is filed on 15/09/2023. It means there is delay of 14 month in filling the case.
- According to the Complainant, the cause of action has arose, when the Complainant raised his objection to grievance cell which was again denied on 21/12/2020 by the Respondent. Thus, as per Hon’ble Supreme Court’s direction dt.23/03/2020 as to extension of limitation period, he is having limitation to file the case. The cause of action arose in between Pandamic of Covid-19. Therefore, there is no delay in the matter.
- Considering the contention and argument of the Complainant, when the cause of action arose on 21/12/2020, then the case should have been filed till 21/12/2022. He has taken shelter of Covid-19 which indeed over when claim has been again rejected by Respondent. As per the directions of the Hon’ble Supreme Court as to limitation, the Complainant has right to file case till 31/05/2022. Such is not the matter of fact. The present case is filed on 15/09/2023. Thus, from 31/05/2022 to 15/09/2023 the delay is of 15months approximately in the matter. However, to condone the above said inordinate delay no evidence with another explanation has been adduced and given by the Complainant. In such manner only one conclusion arises that no sufficient ground has been made out thereto.
- In the above regard, it is well settled law that, mere making correspondence after rejection / repudiation of claim by concern authority, limitation do not stand extended on the basis of correspondence made thereafter.
- Thus, considering the facts, circumstance and evidence of the Complainant, the present case is having bar of limitation as per Sec.69 of the Consumer Protection Act, consequently, the case deserves to be dismissed being barred by limitation.. Hence, we record the finding on the point accordingly and proceed to pass the following order.
Final Order The Consumer Complaint no.146/2023 is hereby dismissed without costs. | |
