ORDER

    Complainant is a mediclaim policy holder of OP 

no.1 vide policy no. 110100/11001/1000207097 -01 

w.e.f. 15-5-2012 to 13-5-2013. 

It is alleged by the complainant that the time of 

renewal of the aforesaid policy in the year 2012 , 

the OP had lodged an extra premium of Rs 8000/- 

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whereafter it was agreed that clause 6 (b) would not 

be enforcible and the time framed U/s 6 (c) & 6 (d) 

shall be reduced to one year and two years 

It is alleged by the complainant that she had 

filed a claim for Rs. 30,148/- regarding treatment of 

IMSC right  eye of her  husband who was admitted on 

8-5-2013 and was discharged  on 8-5-2013 with OP on 

4-6-2013.  The same was repudiated by the OP with the 

following observations-“ the present illness has a 

specific two years of waiting period as per the 

policy and the policy starting date is 14-5-2011.  We 

regret to inform you that your claim is repudiated 

under section 6 c of the policy.” 

It is further alleged by the complainant that 

despit e the fact that the waiting period under 

clause 6 C had been reduced to 1 year, the OP has 

repudiated his claim on false and flimsy ground. 

The complainant had also filed a complaint before 

the insurance ombudsman on 19-7-2013 against the 

repduation. The insurance ombudsman vide its order 

dated 05-2-2015 affirmed the decision of the 

insurance company as right. 

Being aggrieved by the decision of the insurance 

ombudsman , complainant approached this forum for the 

redressal of his grievance. 

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Notice of the complaint was sent to the OP 

through Regd. AD. Post on 24-4-205. The notice was 

not received back unserved , service was , therefore, 

presumed was to have been effected on the OP. since 

none appeared on behalf of OP, it was ordered to be 

Complainant has filed his evidence by way of 

affidavit dated 20-8-2015 in which she has 

corroborated the contents of the complaint. 

We have heard arguments advanced at the bar and 

 The complainant has placed on record the copies of 

health insurance policies issued by the OP year after 

year.  She has also placed on record copy of the 

award passed by insurance ombudsman dated 5-2-2015 

along with its affidavit. 

The complainant has placed on record the copy of 

the policy no. 110100/11001/1000207097 -01, the bare 

perusal of the same clarifies that the waiting period 

for condition no. 6 c has been reduced to one year. 

The complainant has filed his claim for  reinspection 

before the OP for the year 2012-2013 which is in the 

second year of the policy, and as the waiting period 

under clause no. 6 C is reduced to 1 year, the OP 

ought not to have rejected the claim of the 

complainant on the ground that illness is covered 

under section 6 c for which there is a waiting period 

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   This act of the OP amounts to deficiency in 

services. From the unrebutted testimony of the 

complainant as well as the documents placed on 

record. We hold OP guilty of deficiency in services 

1. To pay to the complainant Rs 30,148/- along 

with interest @ 10% p.a. from the date of 

filing of complaint till payment.

2.  To pay to the complainant a sum of Rs. 

10,000/- for mental pain and agony suffered 

3. To pay to the complainant a sum of Rs. 5000/- 

as cost of litigation. 

     The OP shall pay this amount within a period 

of 30 days from the date of this order failing 

which they shall be liable to pay interest on the 

entire awarded amount @ 10% per annum.  IF the OP 

fails to comply with this order, the complainant 

may approach this Forum for execution of the order 

under Section 25/27 of the Consumer Protection Act. 

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.....................