Order No.  11  dt.  15/07/2019

        The case of the complainants in brief is that the complainant while enjoying the mediclaim policy issued by the Oriental Insurance Co. and during the subsistence of the said policy the complainant became ill and he was admitted to hospital on 6^th September,2018 under surgeon Dr. Anjan Das and the complainant underwent an operation though he sought for the cashless claim but the insurance authority refused to accept cashless benefit. On 22^nd September,2018 the complainant submitted bills for reimbursement of the medical expenses incurred by him. The opt. nos. 1 to 3 refused to reimbursement the claim of the complainant. Complainant has also stated that for the purpose of his treatment had to bear an expenses of Rs.1,29,080/- since the claim of the complainant was not entertained for which the complainant filed this case praying for direction upon the o.ps to disburse the medical bill of the complainant with statutory interest and also prayed for compensation of Rs.1 Lakh and litigation cost of Rs.10,000/- respectively.           

            The o.ps nos. contested the case by filing w/v and denied all the material allegations of the complaint. It was stated from the enclosed policy conditions it is clear that ailment as diagnosed by authorities are having 24 months waiting period. It appears from the materials on record as stated by the o.ps. that the policy was opened in the year 2018 and within the stipulated period of 24 months of waiting period the complainant went for the treatment and he incurred expenses for which the o.ps. cannot be held liable for payment of the medical reimbursement of the complainant. It was further stated that in the policy document as per terms and conditions of the policy it was categorically stated that the diseases suffered by the complainant cannot be entertained by the insurance company, if any medical expenses borne by the policy holder within 24 months accordingly, since the complainant before the expiry of the 24 months underwent treatment and asked for the reimbursement of the medical bills which was not released by the o.ps as per terms and conditions of the policy. The policy document is a contract between the parties and the terms and conditions of the policy are binding upon both the parties. Since the complainant applied for the reimbursement of the medical expenses and as per the clause 4.2 general Exclusion Clause claim of the complainant cannot be entertained. In view of the said fact the insurance company categorically stated that there is no deficiency in service on the part of the o.ps and thereby case filed by the complainant is to be dismissed.

            On the basis of the pleadings of parties the following points are to be decided:

1. Whether the complainant is also the policy holder issued by the o.ps?
2. Whether there was any deficiency in service on the part of the o.ps.?
3. Whether the complainants will be entitled to get the relief as prayed for?

Decision with reasons:

            All the points are taken up together for the sake of brevity and avoidance of repetition of facts.

Ld. Lawyer of the complainant argued that the complainant while enjoying the mediclaim policy issued by the Oriental Insurance Co. and during the subsistence of the said policy the complainant became ill and he was admitted to hospital on 6^th September,2018 under surgeon Dr. Anjan Das and the complainant underwent an operation though he sought for the cashless claim but the insurance authority refused to accept cashless benefit. On 22^nd September,2018 the complainant submitted bills for reimbursement of the medical expenses incurred by him. The opt. nos. 1 to 3 refused to reimbursement the claim of the complainant. Complainant has also stated that for the purpose of his treatment had to bear an expenses of Rs.1,29,080/- since the claim of the complainant was not entertained for which the complainant filed this case praying for direction upon the o.ps to disburse the medical bill of the complainant with statutory interest and also prayed for compensation of Rs.1 Lakh and litigation cost of Rs.10,000/- respectively.

            Ld Lawyer of the o.ps argued that stated from the enclosed policy conditions it is clear that ailment as diagnosed by authorities are having 24 months waiting period. It appears from the materials on record as stated by the o.ps. that the policy was opened in the year 2018 and within the stipulated period of 24 months of waiting period the complainant went for the treatment and he incurred expenses for which the o.ps. cannot be held liable for payment of the medical reimbursement of the complainant. It was further stated that in the policy document as per terms and conditions of the policy it was categorically stated that the diseases suffered by the complainant cannot be entertained by the insurance company, if any medical expenses borne by the policy holder within 24 months accordingly, since the complainant before the expiry of the 24 months underwent treatment and asked for the reimbursement of the medical bills which was not released by the o.ps as per terms and conditions of the policy. The policy document is a contract between the parties and the terms and conditions of the policy are binding upon both the parties. Since the complainant applied for the reimbursement of the medical expenses and as per the clause 4.2 general Exclusion Clause claim of the complainant cannot be entertained. In view of the said fact the insurance company categorically stated that there is no deficiency in service on the part of the o.ps and thereby case filed by the complainant is to be dismissed.

            Considering the submissions of the respective parties it is an admitted fact that the complainant obtained mediclaim policy issued by the o.ps in the year 2018. It is also an admitted fact that the complainant became ill in the year 2018 and he underwent treatment at Fortis Hospital for surgery of Benign prostatic hypertrophy and it also appears from the document filed by the complainant that he was/is suffering from hypertension and diabetic. In the policy document it was categorically stated that waiting period of 24 months and after the said period the complainant if would have undergone treatment the insurance company could have reimbursed the medical bills. It appears from the document which is binding upon all the parties and as per clause 4.2 of the Exclusion Clause it was categorically stated that 24 months waiting period from the date of opening of the policy since the complainant suffered illness within a  few months from the date of opening of the policy and, therefore, as per the Exclusion Clause 4.2 the insurance company rightly rejected the claim of the complainant, therefore, we hold that the claim made by the complainant cannot be entertained since the terms and conditions of the policy debarred the insurance company to release the fund in favour of the complainant for the treatment underwent by him. Accordingly, we hold that there is no deficiency in service on the part of the insurance company. The complainant will not be entitled to get any relief as prayed for.  So all the points are disposed of accordingly.

                        Hence, ordered,

            That the CC No. 11/2019 is dismissed on contest without cost against o.ps.