O R D E R <br /> <br /> <br /> SRI. D.KRISHNAPPA., PRESIDENT., <br /> <br /> The grievance of the complainant against the Ops in brief is that he is an employee of Bharat Electronics Officers club taken Swastik Health care Mediclaim policy from 2nd OP which was valid from 28-11-2007 to 27-11-2008 for Rs.1,00,000/-. That he on 28-06-2008 was admitted to Bhagvan Mahaveer Jain Heart centre, under gone surgery and treatment for deep venous thrombosis of legs, pulmonary embolism and IVC filter done and was discharged on 12-07-2008. That he incurred medical expense of Rs.1,24,954/- and made a claim to the Ops who have rejected his claim by issuing a repudiation letter. Therefore calling the act of Ops No:1 to 3 as deficient has prayed for a direction to the Ops to reimburse the insured amount of Rs.1,00,000/- with interest 18% per annum and to award compensation of Rs.2,00,000/-.<br /> <br /> Ops No:1 to 3 have appeared through their advocate and filed version. OP 1 in his version has contended that he is only a corporate agent of insurance company whose duty is to collect premiums from the prospective premium payers and pay the premiums to the insurance company after deducting his commission. His role comes to an end as soon as the company issues the policy. As stated in the case on hand he has paid the premium collected from the complainant to OP 2 who issued the policy. Therefore he has not caused any deficiency in his service as he has forwarded the claim of the complainant to OP 2 who has rejected and therefore has prayed for dismissal of the complaint against him. OP 2 contending that the complaint is not maintainable and he is not liable to pay the relief. This OP further contended that within one year from the date of obtaining the policy the insured is not entitled for reimbursement of treatment expenses for the decade arising within one year and therefore justifying his action in repudiating the claim submitted for dismissing the complaint. The OP further denying his knowledge of ailment and expenditure incurred by the complainant by referring to the clause 4.3 of the insurance policy terms and conditions as stated that the complainant has taken treatment for ailment within one year from the inception of the policy as the result the policy clause 4.3 comes in, as such the complaint is not maintainable and thereby to dismiss the compliant. <br /> <br /> OP 3 in his separate version filed has contended that he is a third party administrator acting on behalf of insurance company OP 2, without denying that the complainant had taken mediclaim policy has contended that within 7 months after the commencement of the policy the complainant has taken treatment for his ailment and that reimbursement is subject to terms and conditions of the policy and that disease for which treatment is taken is not covered in the 1st two year of the policy and by referring to clause 4.3 of the conditions of the policy he has stated that the complainant is not entitled for reimbursement of the amount and justified the action of repudiation. <br /> <br /> In the course of enquiry into the complaint, the complainant and OPs have filed their affidavit evidence reproducing what they have stated in their respective compliant and version. Complainant alongwith the compliant has produced copy of claim form, copy of repudiation letter, copy of the mediclaim policy, hospital discharge summary, copy of the letter containing total amount expenditure incurred in the Hospital with a copy of legal notice he got issued to the Ops. Ops have produced a copy of the conditions of the policy. Counsel for OP 2 has filed his written arguments. We have heard the counsel for the complainant and other Ops and perused the records. <br /> <br /> On the above materials, following points for determination arise.<br /> <br /> 1. Whether the complainant proves that the OPs have caused deficiency in their service in repudiating his claim for reimbursement of medical expenditure? <br /> <br /> 2. To what relief the complainant is entitled to ?<br /> <br /> Our findings are as under:-<br /> <br /> Point No: 1 in the affirmative. <br /> Point No: 2:see the final order.<br /> <br /> REASONS: POINT No:1:: <br /> <br /> As we have referred to the above in brief the contention of rival parties, we find no dispute between the parties in this complaint having had a mediclaim policy for Rs.1,00,000/- which was in effect from 28-11-2007 to 27-11-200. It is the claim of the complainant that he on 28-06-2008 underwent a surgery for deep venous thrombosis of legs, pulmonary embolism and IVC filter in Bhagawan Mahaveer Jain Heart Centre and incurred expenditure of Rs.1,24,954/- . Ops have not seriously disputed the treatment of this complainant underwent and expenditure he incurred. Even then the complainant has produced discharge summary and a copy of bill evidencing payment made to that hospital. <br /> <br /> The 1st Op claimed that it is only a corporate agent acting has an agent of insurance companies claim to have collected insurance premiums from the complainant paid to Ops 2 the company and got issued a policy after collecting his commission. Therefore as rightly stated by him once OP 2 has issued a policy, his liability seizes therefore no liability can be attached to this OP 1. <br /> <br /> Op 2 is the insurance company which issued the policy in favour of the complainant and 3rd Op is the 3rd party administrator has taken the responsibility of processing and scrutinizing the claim of the insured and either make payment or repudiate the claim. In this case OP 2 and 3 have admitted to had repudiated the claim of the complainant by invoking clause 4.3 of the policy. Therefore the entire case rests on the applicability of clause 4.3 of the policy clauses and correctness and otherwiseness of the repudiation of the claim made by this Ops 2 and 3. In order to understand whether repudiation is right or wrong it is necessary to reproduce clause 4.3 of the clause of the policy as it stand at this juncture. <br /> <br /> Clause 4.3:: “During the 1st year of the operation of the policy, the expenses on treatment of diseases such as cataract, Benign, prostatic, Hyperthrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal disease, Fistula in anus, piles, sinusitis and related disorders are not payable. If these diseases (other than congenital internal disease) are pre-existing at the time of proposal they will not be covered even during subsequent period of renewal. If the insured is aware of the existence of congenital internal disease before inception of policy, the same will be treated as pre-existing”.<br /> <br /> <br /> On going through this clause 4.3 which comes within the exclusions of the policy, it reads that during the 1st year of the operation of the policy the expenses on treatment of certain diseases or pre-existing diseases are not covered and therefore is not payable. The Opponents No:2 and 3 found to have specifically come out as to on what ground the claim of the complainant is repudiated. Clause 4.3 contain two contingencies one is not permitting reimbursement of medical expenditure within the period of one year from the date of commencement of policy for certain diseases mentioned therein, secondly if treatment is taken for diseases which was pre-existing. On going though the entire contents of clause 4.3 as quoted above the case of the complainant in our view is not at all excluded. Because it is not the case of OP 2 and 3 that the ailment for which the complainant has undergone surgery is included as the ailment in respect of which, if treatment is taken within one year, its expenditure is excluded. It is also not the case of the Ops 2 and 3 that this complainant had pre-existing disease that means that he was having the disease even prior to the inception of the policy. Therefore if these two bars are excluded absolutely we find no exclusions under the conditions of the policy for OP 2 and 3 to refuse the claim of the complainant. Therefore considering clause 4.3 of the exclusions of the policy we hold that it is not applicable to the claim of the complainant and therefore repudiation is not sustainable and that repudiation of the claim of the complainant is deficient and thus the complaint deserves to be allowed. As a result we answer point No:1 in the affirmative and pass the following order. <br /> <br /> O R D E R<br /> <br /> Complaint is allowed. OP 2 and 3 are held jointly and severally deficient and are directed to reimburse Rs.1,00,000/- towards medical expenses of the complainant with interest @ 9% per annum from the date of his claim till it is reimbursed. <br /> <br /> Ops 2 and 3 shall also pay cost Rs.2000/- to the complainant. <br />