The Complainant has filed this case alleging deficiency-in-service by the O.Ps, where O.P No.1 is the M.D, Heritage Health TPA Pvt. Ltd., Kolkata, O.P No.2 is the M.D, New India Assurance Company Ltd., Mumbai, O.P No.3 is Regional Manager, Heritage Health TPA Pvt. Ltd., Bhubaneswar and O.P No.4 is the Divisional Manager, New India Assurance Co. Ltd., Balasore. 

                    1. Shorn of unnecessary details briefly stated the case of the Petitioner is that the Complainant had purchased an individual Policy from O.Ps bearing Card No. HHS2.0500336880 and  Policy No.55080034130100000017 and valid up to 09.06.2014. The Complainant was admitted to Sonar Hospital, B.K Road, Cuttack on 25.08.2013 and discharged on 29.8.2013, being operated on  26.08.2013. The Complainant was suffering from “AV Bulky Uterus with Lt. parovarian cyst” disease, for which operation was done. Thereafter, the Complainant submitted all the documents on 24.09.2013 before the O.Ps for settlement of claim and submitted the compliance documents on 06.12.2013. But the O.P No.4 dispatched a letter to the Complainant stating the reason delay in submission of claim from i.e. after 40 days of discharge by the Complainant. The Complainant also issued legal notice through her Advocate to the O.Ps. Reply letter of the O.Ps dt.26.06.2014 is annexed herewith. Prayer for payment of claim amount, along with interest, compensation and cost of litigation.

                    2. Sufficient opportunities were given to the O.Ps No.1 & 3, but they did not appear in this case, hence they are made set ex-parte.

                    3. The O.P No.2 & 4 appeared through their Advocate and filed their written version, in which they have taken the plea that the husband of the Complainant has not intimated to O.P No.1 within 7 days of the hospitalization of the Complainant, but submitted 40 days after her discharge. The husband of the Complainant had not also submitted some important and relevant documents along with the claim form. The O.P No.1 informed to the husband of the complainant on 06.12.2013 and also to inform the reason for delay in intimation and also to submit condone letter from O.P No.4. But the husband of the Complainant did not respond, for which the O.P No.1 intimated to O.P No.4 on 28.02.2014. The O.P.No.4 forwarded copy of the letter of O.P No.1 to the husband of the Complainant on the same day i.e. on 28.02.2014, to comply the requirement asked by the O.P No.1. Thereafter, the husband of the Complainant had been to O.P No.4 on 03.03.2014 and informed them delay in intimation is due to his illness. But he could not file/submit documents in support of his illness. Thereby, the O.P No.4 considered that the delay in intimation and submission of claim from is deliberate one and accordingly, the O.P No.4 sent a Mail to the O.P No.1 on 25.06.2014. In between, the husband of the Complainant submitted some relevant documents in connection with settlement of claim of the Complainant before the O.P No.3 on 09.06.2014, which the O.P No.3 forwarded the said documents to the O.P No.1, which was received by them on 12.06.2014.

                    4. On perusal of the documents available in the case record and the documents filed by both the contesting Parties, it is noticed that:-

 (i) On scrutiny of the claim form along with the enclosures submitted by the Complainant, the O.P No.1 noticed that the Complainant was admitted in “Sonar Hospital at Cuttack on 25.08.2013 for Ovarian Cystectomy operation and further noticed that the husband of the Complainant has taken the Mediclaim Policy-2007 on 10.06.2013 for the first time and the reimbursement for expenses is claimed within third months of taking such policy. All internal and external benign tumors, cysts, polyps of any kind including benign breast lumps are not covered for two years, as per clause No.4.3 of schedule for Mediclaim Policy-2007. As such the O.P No.1 repudiated the claim and intimated to the husband of the Complainant on 07.07.2014.

(ii) Thus, the Advocate for O.P No.2 & 4 has relied upon the decision of Hon’ble National Commission, New Delhi in the matter of Bajaj Allianz General Insurance Co. Ltd. (Vs.) Sri Ashish Saxena, reported in 2015(2) CPR-5 (N.C), in which it has been held that claim of the Policy holder is inadmissible for excluding in terms of Mediclaim Policy issued.

                    5. In the instant case, the Medicalim Policy-2007 available in this case record discloses that in Clause No.4.3 of the Schedule in Sl. No.2 that all internal and external benign tumors, cysts, polyps of any kind including benign breast lumps excluded within two years. In instant case, the Patient/ Complainant was treated and operated on 26.08.2013 and discharged on 29.08.2013 for her disease ‘AV Bulky Uterus with Lt. parovarian cyst’. The period of insurance of Mediclaim is from 10.06.2013 to 09.06.2014 as disclosed from the Policy schedule available in this case record. The prescribed disease, for which she was treated and operated does not cover in the prescribed period as mentioned in documents available in the case record, which is supported in the authority mentioned above. So in this circumstances, the Forum is of the opinion that Complainant is not entitled for her claim prayed for, in view of the Mediclaim Policy, for which this Consumer case is liable to be dismissed. Hence Ordered:- 

                                                     O R D E R

                         The Consumer case is dismissed on contest against the O.Ps No.2 & 4 and on ex-parte against O.P No.1 & 3.

                         Pronounced in the open Forum on this day i.e. the 20th day of March, 2017 given under my Signature & Seal of the Forum.