Jharkhand

Bokaro

CC/17/117

Usamn Ansari - Complainant(s)

Versus

The Director, Religare Health Insurance Co. Ltd. - Opp.Party(s)

Md.Ataullah Ansari

29 Jan 2022

ORDER

 

1.              Complainant has filed this case with prayer for direction to O.Ps. to pay insurance claim related to medical expenses of  Rs. 11,200/- with 12% interest and for payment of Rs. 10,000/- and Rs. 6000/- as compensation and litigation cost respectively.
2. Complainant’s case in brief is that he obtained Group Insurance Policy No.10087119 of the plan Group Care, on 24.04.2015, which was renewed and was effective from 24/04/2016 to 23/04/2017.  Further case is that due to illness complainant was treated in Bokaro General Hospital (in short BGH) and Medanta Abbul Razzaque Ansari Memorial Weavers Hospital, Ranchi (in short Medanta Ranchi) and submitted claim vide claim No. 90267320 dt. 10.11.2016 for Rs. 11,200/- but it was denied on 16.05.2017 on the ground that it is not registered with O.P. as this comes within exclusion and for policy terms and conditions. Thereafter, Legal Notice was sent having no effect hence case has been filed.
3. On issuance of notice both O.Ps. appeared amongst them O.P. No.2 has filed W.S. mentioning therein that he is having no liability rather he only acted as mediator to facilitate opening of insurance policy hence this Bank is having no liability in respect to re-imbursement etc.
4.    O.P. No.1 has filed W.S. in which facts related to opening of insurance policy, submission of claim papers for re-imbursement and denial of the claim are admitted facts. As per O.P. No.1 the claim of the complainant was in respect to treatment of the diseases which were excluded for two years waiting period  as per terms and conditions of the policy bond hence company has rightly rejected the claim.
5.   On careful perusal of the pleadings of the parties it appears that only point in controversy is whether complainant is entitled to get re-imbursement of the treatment cost of the diseases for which he was treated within 2 years of the opening of the policy?
6.    It is admitted fact that alleged Group Policy for medical insurance was opened by the O.P. No. 1 Religare Health Insurance Co. Ltd. in favour of the complainant commencing from 24.04.2015 and it was renewed later on and was valid till 23.04.2017. Another admitted fact is that policy papers were furnished to the complainant.
7.     It is known fact that insurance policy is being opened on the basis of proposal submitted by an individual or any other person(insured person) and on its acceptance by the insurance co. it takes form of a contract. It is known to all that both parties of the contract are expected to abide the terms and conditions of the contract. Now we will discuss about the terms and conditions of the contract. As per paper submitted by the complainant firstly he was treated at BGH for NSAID induced UGI bleeding for which Endoscopy was done on 30.09.2016. The copy of discharge ticket dt. 12.09.2016 shows that there was UGI bleeding and Gastritis. Thereafter, complainant was treated at Medanta Ranchi on 21.09.2016 for Neck pain since one year and Restricted  neck movement since three days. It is said that MRI was done and it was diagnosed that patient was suffering with changes of cervical spondylosis. It is important to note here that MRI scan was done on 10.02.2016 and payment of Rs. 6000/- has been made for MRI on 10.02.2016 but there is no claim by the complainant in respect to that very expense related to MRI rather claim has been made in respect to treatment at BGH from 09.09.2016 to 12.09.2016 and treatment done at Medanta, Ranchi  on 21.09.2016.The prescription of Medanta shows that no MRI has been suggested by the expert Doctor. However, complaint petition is silent in respect to date of treatment.
8.     At this place we would like to extract some relevant portion of page 3 and 4 of the terms and conditions of the contract made between the parties in which at serial No.3 waiting period related to Exclusion of the disease has been mentioned as follow:-

Key Exclusions

3. 1 (b) specific waiting period

Any Claim for or arising out of any of the following illness or Surgical Procedures shall not be admissible during the first 24 consecutive months from the first Cover Start date with Us:

1. Arthritis (if non- infective) Osteoarthritis and Osteoporosis Gout Rheumatism and  special disorders joint replacement Surgery.

(vi) Fissure/Fistula in anus. Hemorrhoids/piles Pilonidal Sinus, Gastric and Duodenal Ulcers.

9       Now we have to examine the claim in light of agreement/contract arrived at between the parties. Insurance Policy was started on 24.04.2015, therefore, two years period will continue till 23.04.2017 and above mentioned exclusions of two years will applicable till 23.04.2017 but here in this case claim has been made for the treatment done on 09.09.2016 and 21.09.2016 which comes within the exclusion clause of two years. It is important to mention here that the complainant has intentionally not disclosed the date of treatment just to suppress material facts. In this way complainant has not come before this Commission with clean hands.

10. In light of above discussion we are of the opinion that rejection of   claim  by O.P. No.1 is justified and in accordance with terms and conditions of the contract and there is no deficiency in service.
11.     Hence this case is being dismissed with cost.