1) Smt. Soma Nahata,
2, India Exchange Place, Kolkata-1. _________ Complainant
____Versus____
1) Reliance Genral Insurance Co. Ltd.,
38-B, Jawaharlal Nehru Road, 8th Floor,
P.S. Shakespeare Sarani, Kolkata-71 and
Oswal Chambers, 2nd Floor,
2, Church Lane, Kolkata-1.
2) Medi Assist,
“Ganga Apartment”,
86, Golaghata Road, 2nd Floor, Kolkata-48. _________ Opposite Parties
Present : Sri Sankar Nath Das, President.
Dr. Subir Kumar Chaudhuri, Member.
Smt. Samiksha Bhattacharya, Member
Order No. 28 Dated 13/01/2014
The case of the complainant in short is that complainant and her husband obtained a Healthwise policy of o.p. no.1 under the name and style ‘Reliance Healthwise Policy’ and the said policy was valid for the period 31.3.09 to 31.3.10. During continuation of the said policy period the complainant admitted in Bellevue Clinic on 16.3.10 and discharged on 19.3.10 for treatment of her illness in respect of pain in right iliac fosa. The complainant submitted a claim for Rs.48,654/- on 19.4.10 and the said claim was registered vide no.4957236 under the policy no.28251025217401. O.ps. accepted the claim, process the same and finally o.p. no.2 intimated the complainant by their letter dt.17.5.10 that as per policy exclusion clause no.3 insured is not entitled to get any claim. Complainant states that exclusion does not apply for insured having any health insurance policy in India at least for one year prior to taking this policy as well as for subsequent renewal without break. The repudiation on the basis of said exclusion clause cannot hold good and o.ps. are liable for their negligence and deficiency in service. Hence the instant application with prayer to allow the claim amounting to Rs.48,654/- along with compensation with cost.
Though the notices were served upon o.p. nos1 and 2 o.p. no.2 did not appear before this forum and the matter was fixed ex parte as against o.p. no.2. In their w/v o.p. no.1 denied all material allegations interalia stated that validity of the policy in question was from 1.4.09 to 31.3.10 but not from 31.3.09 to 31.3.10. The complainant along with her claim petition has annexed another policy valid from 1.4.07 to 31.3.08. But in the said policy the present complainant was not covered as insured and hence the same has no connection with the present case. O.p. no.1 also argued that as complainant’s case clearly fall under exclusion clause of the concerned policy of insurance her claim has been rightly repudiated and as such, there is no deficiency in service on the part of o.p. Therefore, the present case is liable to be dismissed with heavy cost.
Decision with reasons:
We have gone through the pleadings of the parties, evidence and documents in particular. It is admitted fact that complainant obtained a Healthwise policy from o.p. no.1 and the said policy period was w.e.f. 1.4.09 to 31.3.10. The complainant was treated for Luteal Cyst Rupture during period from 16.3.10 to 19.3.10 i.e. within validity period of first year of policy in respect of this complainant. The complainant was admitted due to cyst related disease which is not covered by the said policy of insurance in its very first year in respect of this complainant. O.p. no.1 has annexed the policy condition with their w/v. In policy exclusion clause no.3 it is clearly mentioned that cyst related disease is excluded within the first year from the inception of this policy. In the present case the complainant’s husband policy was for more than year but the complainant was included in the said policy from 1.4.09. Hence the treatment was done within the first year of the said policy. In this connection we have relied upon the decision of Hon’ble Supreme Court of India reported in AIR 1966 SC 1644 in which Hon’ble Court has observed that “The reason of rules appears to be that where parties agree upon certain terms which are to regulate their relationship. It is not for the court to make a new contract, however reasonable, if the parties have not made it for themselves”. After receiving w/v along with annexures from o.p. no.1 the complainant has not made any attempt to prove such questions of facts by tendering any evidence thereof. Therefore the complainant has failed to substantiate her case and as such, she is not entitled to get any relief.
Hence, ordered,
That the case is dismissed on contest against o.p. no.1 and ex parte against o.p. no.2.
