State Consumer Disputes Redressal Commission
The Oriental Insurance Co.Ltd. vs Vipin Singhaniya on 4 October, 2019
NRrhlx<+ jkT;
miHkksDrk fookn Áfrrks"k.k vk;ksx] iaMjh] jk;iqj vihy Øekad% FA/2019/445 lafLFkr fnukad: 18.07.2019.
fn vksfj;saVy ba';ksjsal daiuh fyfeVsM] }kjk&ofj"B eaMy izca/kd] eaMy dk;kZy; dzekad&02] f}rh; ry] pkaoyk dkWEiysDl] nsosUnz uxj jksM] lkabZ uxj] jk;iqj ¼N-x-½ ----------------vihykFkhZ@vukosnd-
fo:) fofiu fla?kkfu;k vk- Jh ,l- ,u- vxzoky] mez&45 o"kZ] fuoklh&vkdk'k xaxk] 3@1019] xhrk uxj ¼pkScs dkWyksuh½] jk;iqj] rglhy o ftyk&jk;iqj ¼N-x-½ -------------mRrjoknh@ifjoknh- le{k% ekuuh; U;k;ewfrZ Jh lh- ch- cktis;h] v/;{k-
ekuuh;k Jherh :fp xks;y] lnL;k -
i{kdkjksa ds vf/koDrk vihykFkhZ dh vksj ls Jh f'kf'kj HkaMkjdj] vf/koDrkA mRrjoknh dh vksj ls Jh uohu vkgwtk] vf/koDrkA vkns'k fnukad% 04@10@2019 }kjk%&ekuuh;k Jherh :fp xks;y] lnL;k vihykFkhZ@vukosnd us ;g vihy /kkjk&15 miHkksDrk laj{k.k vf/kfu;e] 1986] ds rgr ftyk miHkksDrk fookn izfrrks"k.k Qksje] jk;iqj ¼N-x-½ ¼ftls vkxs laf{kIr esa **ftyk Qksje** lacksf/kr fd;k tk,xk½ ds ifjokn izdj.k dzekad&133@2010 fofiu fla?kkfu;k fo:} fn vksfj;saVy ba';ksjsal daiuh fyfeVsM esa ikfjr vkns'k fnukad&29 ebZ 2019 ftlds // 2 // }kjk mRrjoknh@ifjoknh ds ifjokn dks Lohdkj djrs gq, ;g vknsf'kr fd;k x;k gS fd%& **v- vukosnd chek daiuh] ifjoknh dks laiw.kZ fpfdRlk nkok jkf'k 1]23]792-64 ¼,d yk[k rsbZl gtkj lkr lkS c;kucs :Ik;s pkSalB iSls½ ifjokn fnukad&08-03-2010 ls vnk;xh fnukad rd 09 izfr'kr lk/kkj.k okf"kZd C;kt lfgr vnk djsxkA c- vukosnd chek daiuh] ifjoknh dks mijksDr d`R; ds dkj.k gqbZ ekufld d"V ds fy, 10]000@&¼nl gtkj :Ik;s½ vnk djsxkA l- vukosnd chek daiuh] ifjoknh dks vf/koDrk 'kqYd rFkk oknO;; ds :Ik esa 2]000@&¼nks gtkj :Ik;s½ Hkh vnk djsxkA** ls nqf[kr gksdj izLrqr fd;k gSA 02- mRrjoknh@ifjoknh dk ifjokn ftyk Qksje ds le{k laf{kIr esa bl izdkj jgk gS fd mRrjoknh@ifjoknh us o"kZ 2002&03 esa fn U;w bafM;k ba';ksjsal daiuh fyfeVsM ls Lo;a ds uke ls rFkk viuh iRuh ds uke ls ,d O;fDrxr fpfdRlk nkok gsrq ,d Hospitalization and Domivilary Hospitalization Benefit Policy fu;ekuqlkj izhfe;e iVkdj izkIr dh Fkh ftldk ikWfylh dzekad&450301@48@01@06586 Fkk tks fnukad&11-03-2002 ls 10-03-2003 dh v}Zjkf= rd oS/k FkhA mDr ikWfylh ifjoknh ,oa mldh iRuh ds uke ij izR;sd O;fDrxr ds fy, 1]00]000&1]00]000@&¼,d&,d yk[k :Ik;s½ ds chfer FkhA mRrjoknh@ifjoknh us o"kZ 2003&04 ds fy, Hkh mijksDr chek daiuh us // 3 // Lo;a ds uke ls ,oa viuh iRuh ds uke ls ,d O;fDrxr fpfdRlk nkok gsrq Hospitalization and Domivilary Hospitalization Benefit Policy fu;ekuqlkj izhfe;e iVk dj izkIr dh Fkh ftldk ikWfylh dzekad&450301@48@02@01131 Fkh tks fnukad&11-03-2003 ls 10-03- 2004 dh v}Zjkf= rd oS/k FkhA mDr ikWfylh Hkh ifjoknh ,oa mldh iRuh ds uke ij izR;sd O;fDrxr ds fy, 1]00]000&1]00]000@& ¼,d&,d yk[k :Ik;s½ ds chfer FkhA mRrjoknh@ifjoknh us o"kZ 2004&05 ds fy, Hkh mijksDr chek daiuh us Lo;a ds uke ls ,oa viuh iRuh ds uke ls ,d O;fDrxr fpfdRlk nkok gsrq Hospitalization and Domivilary Hospitalization Benefit Policy fu;ekuqlkj izhfe;e iVk dj izkIr dh Fkh ftldk ikWfylh dzekad&450301@48@03@01653 Fkh tks fnukad&11-03-2004 ls 10-03-2005 dh v}Zjkf= rd oS/k FkhA mDr ikWfylh Hkh ifjoknh ,oa mldh iRuh ds uke ij izR;sd O;fDrxr ds fy, 1]00]000&1]00]000@& ¼,d&,d yk[k :Ik;s½ ds chfer FkhA 2005&06 ds fy, Hkh mijksDr chek ikWfylh mRrjoknh@ifjoknh us vius o viuh iRuh ds uke ls mijksDrkuqlkj izhfe;e iVkdj izkIr fd;k ftldk ikWfylh dzekad&450301@48@04@75145 Fkh tks fnukad&11-03-2005 ls 10-03-2006 dh v}Zjkf= rd oS/k FkhA 2006&07 ds fy, Hkh mRrjoknh@ifjoknh us vihykFkhZ@vukosnd ls vius o viuh iRuh ds uke ls O;fDrxr fpfdRlk nkok gsrq fu;ekuqlkj izhfe;e iVkdj izkIr dh Fkh ftldk ikWfylh dzekad&1497@2006 Fkh tks fnukad&11-03-2006 ls 10-03-2007 dh e/; jkf= rd oS/k FkhA mDr ikWfylh ifjoknh ,oa // 4 // mldh iRuh ds uke ij izR;sd O;fDrxr ds fy, 1]00]000&1]00]000@&¼,d&,d yk[k :Ik;s½ ds chfer FkhA 2007&08 ds fy, Hkh mRrjoknh@ifjoknh us vihykFkhZ@vukosnd ls vius o viuh iRuh ds uke ls O;fDrxr fpfdRlk nkok gsrq fu;ekuqlkj izhfe;e iVkdj izkIr dh Fkh ftldk ikWfylh dzekad&1656@2007 Fkh tks fnukad&11-03- 2007 ls 10-03-2008 dh e/; jkf= rd oS/k FkhA mDr ikWfylh ifjoknh ,oa mldh iRuh ds uke ij izR;sd O;fDrxr ds fy, 1]00]000&1]00]000@&¼,d&,d yk[k :Ik;s½ ds chfer FkhA 2008&09 ds fy, Hkh mRrjoknh@ifjoknh us vihykFkhZ@vukosnd ls vius o viuh iRuh rFkk vius nks ukckfyx cPpksa oSHko vkSj ekulh ds fy, Hkh O;fDrxr fpfdRlk nkok gsrq Hospitalization and Domivilary Hospitalization Benefit Policy fu;ekuqlkj izhfe;e iVkdj izkIr dh Fkh ftldk ikWfylh dzekad&153600@48@2008@1128 Fkh tks fnukad&14- 03-2008 ls 13-03-2009 dh e/; jkf= rd oS/k FkhA mDr ikWfylh ifjoknh ,oa mldh iRuh ds uke ij izR;sd O;fDrxr ds fy, 2]00]000&2]00]000@&¼nks&nks yk[k :Ik;s½ ds chfer Fkh rFkk blh ikWfylh esa nks ukckfyx cPpksa ds fy, izR;sd O;fDrxr ds fy, 1]00]000&1]00]000@&¼,d&,d yk[k :Ik;s½ ds fy, chfer djk;k x;kA bl izdkj mRrjoknh@ifjoknh yxkrkj fcuk fdlh pwd ds o"kZ 2002 ls o"kZ 2009 rd fu;ekuqlkj izhfe;e vnk dj esfMDyse ikWfyfl;ka izkIr djrs jgkA o"kZ 2008 esa vizSy&ebZ esa mRrjoknh@ifjoknh dks vius ck,a da/ks ds ikl vpkud lkeus dh vksj ,d lwtu lh izrhr gqbZ ftldh // 5 // tkap mlus loZizFke MkW- lquhy dkyM+k ls fnukad&07-05-2008 dks igyh ckj djkbZ rc MkW- lquhy dkyM+k ls mRrjoknh@ifjoknh dh mDr lwtu dks igyh ckj dsykWbM ds :Ik esa igpku fd;kA mRrjoknh@ifjoknh vkxs vkSj fof'k"V tkap gsrq bUnzizLFk viksyks gkWfLiVy] ubZ fnYyh x;k tgka fnukad&15-05-2008 dks ofj"B lykgdkj MkW- yksds'k dqekj us Hkh mDr lwtu dks izFke n`"V;k dsykWbM ds :Ik esa igpku dh rFkk lwtu dh fof'k"V tkap ,oa igpku gsrq ckW;ksIlh dh lykg nh rc mRrjoknh@ifjoknh us mDr lwtu dh mlh gkWfLiVy esa ckW;ksIlh djkbZ ftldh fjiksVZ esa mDr lwtu dks Dermetofibro Sarcoma Protuberaus ik;k x;kA mRrjoknh@ifjoknh }kjk iqu% fnukad&21-05-2008 dks VkVk eseksfj;y gkWfLiVy] eqEcbZ esa mDr lwtu dh tkap djokbZ ftlesa Hkh MkWDVjksa us ;g ik;k fd mRrjoknh@ifjoknh dh mDr lwtu dks dsykWbM ds :Ik esa igpku dh xbZA mRrjoknh@ifjoknh jktho xka/kh dSUlj baLVhV~;wV] ubZ fnYyh esa viuh tkap MkW- dfiy dqekj] ofj"B lykgdkj] lftZdy vkSudksykWth ls djokbZ ftUgksaus bUnzizLFk viksyks gkWfLiVy] ubZ fnYyh ls izkIr ckW;ksIlh fjiksVZ fnukad&20-05-2008 ds vk/kkj ij mRrjoknh@ifjoknh dks mDr lwtu dh 'kY; fpfdRlk dh lykg nh ftudh lykg ij mRrjoknh@ifjoknh us jktho xka/kh dSalj baLVhV~;wV] ubZ fnYyh esa vius ck,a da/ks ds lkeus dh vksj dh lwtu dh 'kY; fpfdRlk lQyrkiwoZd fnukad&24-05-2008 dks iw.kZ fd;k vkSj 'kY; fpfdRlk mijkar da/ks ls fudkyh xbZ iwjh lwtu@xkaB dh nqckjk fnukad&27-05-2008 dks ckW;ksIlh jktho xka/kh dSalj baLVhV~;wV] ubZ fnYyh // 6 // esa dh xbZ ftlesa mDr lwtu@xkaB dks Dermetofibro Sarcoma Protuberaus gh ik;k x;k vkSj fnukad&31-05-2008 dks mRrjoknh@ifjoknh dks fMLpktZ fd;k x;kA mDr 'kY; fpfdRlk ds iwoZ mRrjoknh@ifjoknh dk dksbZ vkWijs'ku ugha gqvk ,oa og lkekU; O;fDr dh rjg thou O;rhr djrk jgk ,oa mls ,slh dksbZ Hkh ?kkrd chekjh ugha Fkh ftlds dkj.k og dHkh gkWfLiVy esa HkrhZ gqvk gks vFkok mldk dksbZ vkWijs'ku gqvk gksA mRrjoknh@ifjoknh ds firk us fu;ekuqlkj fnukad&26-05-2008 ds i= }kjk vihykFkhZ@vukosnd dks lwpuk fn;k fd og vLirky esa HkrhZ gSA vkWijs'ku ds mijkar mRrjoknh@ifjoknh us ubZ fnYyh ls okil vkdj fu;ekuqlkj 1]23]792-64 ¼,d yk[k rsbZl gtkj lkr lkS c;kucs :Ik;s pkSalB iSls½ dk esfMDyse leLr nLrkostksa@fcyksa ds lkFk fnukad&14-07- 2008 ds vkl&ikl vihykFkhZ@vukosnd ds ikl Hkqxrku gsrq tek fd;k ftls vihykFkhZ@vukosnd us vius i= fnukad&22-07-2008 ds }kjk bl vk/kkj ij fd mRrjoknh@ifjoknh dks foxr 05 o"kksZa ls mDr chekjh gS rFkk Pre-Existing Disease gksus ds dkj.k 'krksZa ds vuqlkj oftZr gksus ls mRrjoknh@ifjoknh dk fpfdRlk chek fujLr dj fn;kA mRrjoknh@ifjoknh us vius i= fnukad&22-08-2008 ds }kjk vius fpfdRlk nkos ij iqu% fopkj djus gsrq fuosnu fd;k ftls vihykFkhZ@vukosnd us yxHkx 01 o"kZ mijkar vius i= fnukad&02-07- 2009 ds }kjk Pre-Existing Disease dk gokyk nsrs gq, iqu% fujLr dj fn;k ftlds dkj.k mRrjoknh@ifjoknh dks ;g ifjokn ykus dh // 7 // vko';drk iM+h gSA vr% ifjokn&i= esa of.kZr vuqlkj vuqrks"k fnykbZ tkosA 03- vihykFkhZ@vukosnd dh vksj ls ftyk Qksje ds le{k fyf[kr dFku izLrqr dj ;g vfHkopu fd;k x;k gS fd mRrjoknh@ifjoknh }kjk vihykFkhZ@vukosnd ls loZizFke O;fDrxr esfMDyse ikWfylh fnukad&11-03-2006 ds 2%20 nksigj ls ysdj fnukad&10-03-2007 dh e/; jkf= rd ds fy, izLrqr i=d Hkjus ds Ik'pkr~ fu/kkZfjr 'krksZa] fucZU/kuksa ,oa viotZukvksa ds v/khu izkIr dh Fkh tks fd dze'k%11-03-207 ,oa 11-03- 2008 dks chek ikWfylh dzekad&1656@07 ,oa 1128@08 }kjk uohuhd`r dh xbZ] ijUrq mRrjoknh@ifjoknh }kjk vihykFkhZ@vukosnd ls izFke ckj O;fDrxr esfMDyse ikWfylh dz-&1497@06 ysrs le; izLrko i=d esa viuh 'kkjhfjd fLFkfr ,oa chekfj;ksa ds laca/k esa lgh tkudkjh ugha nh xbZ FkhA Qyr% vihykFkhZ@vukosnd }kjk mRrjoknh@ifjoknh ij iw.kZ fo'okl j[krs gq, mDr chek ikWfylh tkjh dj nh xbZ Fkh tks fd chek ikWfylh dh 'krksZa] fucZU/kuksa ,oa viotZukvksa ds v/;k/khu FkhA mRrjoknh@ifjoknh }kjk vius nkok izi= ds lkFk izsf"kr nLrkostksa esa ls mlds fpfdRld MkW- dfiy dqekj }kjk Hkjdj nh xbZ tkudkjh rFkk vU; fpfdRldh; nLrkostksa ls ;g Li"V :Ik ls izekf.kr Fkk fd mRrjoknh@ifjoknh mDr dsykWbM uked chekjh ls foxr 05 o"kksZa ls ihfM+r Fkh ftldh tkudkjh mRrjoknh@ifjoknh dks izkjaHk ls gh FkhA vihykFkhZ@vukosnd }kjk mRrjoknh@ifjoknh }kjk izLrqr fpfdRldh;
// 8 // nLrkostksa ds izkIr gksus ij mDr nLrkost chek daiuh }kjk vius iSuy fpfdRld MkW- lR;thr lkgw dks vfHker gsrq Hksts x;s ftUgksaus mDr nLrkostksa dk ifj'khyu dj ;g vfHker fn;k fd pwafd mRrjoknh@ifjoknh chek ikWfylh ds vfLrRo esa vkus ls iwoZ ls gh Pre- Existing Disease ls ihfM+r Fkk blfy, mldk nkok iz'uxr chek ikWfylh ds varxZr ns; ugha FkkA mRrjoknh@ifjoknh dks ;|fi vius mDr chekjh ds laca/k esa iwoZ ls tkudkjh Fkh ijUrq mlds }kjk vihykFkhZ@vukosnd ls izFke ckj chek ikWfylh fnukad&11-03-2006 dks izkIr djrs le; Hkjs x, iziksty QkeZ eas mYys[k ugha fd;k x;k tks fd ikWfylh ds viotZu dz-& 4-1 ds varxZr vioftZr Fkk ftlds vuqlkj dksbZ Hkh Pre-Existing gsYFk daMh'ku ;k chekjh ;k jksx tks fd vihykFkhZ@vukosnd ls izFke ckj ikWfylh ysrs le; vfLrRo esa jgh gks rks os chekfj;ka vkxkeh 04 o"kksZa rd mDr chek ikWfylh ds yxkrkj vfLrRo esa jgus ij ikWfylh ds varxZr vioftZr jgsaxhA mRrjoknh@ifjoknh chek ikWfylh ds izFke ckj vfLrRo esa vkrs le; dsykWbM uked chekjh tks fd dkykUrj esa **MjesVksQkbZczks lkjdksek izksV~;wcsjl** esa rCnhy gks xbZ ls ihfM+r Fkk blfy, vihykFkhZ@vukosnd chek daiuh ikWfylh ds viotZu dz-&4-1 ds vuqlkj mDr chekjh ds bZykt esa gq, [kpZ ds isVs mRrjoknh@ifjoknh dks dksbZ Hkh jde vnk djus gsrq nkf;Rok/khu ugha FkhA ifj.kker% vihykFkhZ@vukosnd }kjk vius i= fnukad&22-07-2008 ds }kjk mRrjoknh@ifjoknh dk nkok mijksDr vk/kkj ij vLohdkj dj fn;k x;k vkSj ml ij iquZfopkj dh dksbZ laHkkouk ugha Fkh blfy, // 9 // vihykFkhZ@vukosnd }kjk mRrjoknh@ifjoknh dk nkok vius i= fnukad&02-07-2009 ds }kjk Hkh fujLr gh j[kk x;k vkSj ,slk dj vihykFkhZ@vukosnd }kjk lsok esa dksbZ fuEurk ugha dh xbZ gSA mRrjoknh@ifjoknh] vihykFkhZ@vukosnd ls dksbZ vuqrks"k izkIr djus dk vf/kdkjh ugha gSA vr% mRrjoknh@ifjoknh dk ifjokn lO;; fujLr fd;k tkosA 04- mRrjoknh@ifjoknh dh vksj ls vius i{k leFkZu esa ftyk Qksje ds le{k Lo;a dk 'kiFk&i= rFkk lwph vuqlkj nLrkost izLrqr fd, x, gSaA 05- vihykFkhZ@vukosnd dh vksj ls vius i{k leFkZu esa ftyk Qksje ds le{k vuax iky flag iaokj ofj"B eaMy izca/kd] MkW- lR;thr lkgw] ds- lh- bZIiu ofj"B eaMy izca/kd dk 'kiFk&i= ,oa lwph vuqlkj nLrkost izLrqr fd, x, gSaA 06- ftyk Qksje us mHk;i{kksa dh vksj ls izLrqr vfHkopu ,oa nLrkosth lk{;ksa ds ifj'khyu Ik'pkr~ mRrjoknh@ifjoknh ds ifjokn dks Lohdkj djrs gq, Åij dafMdk&1 esa of.kZr vuqlkj vuqrks"k iznku fd;k gS ftlds fo:} ;g vihy gSA 07- vihykFkhZ@vukosnd dh vksj ls milatkr gksus okys fo}ku vf/koDrk Jh f'kf'kj HkaMkjdj dk ;g rdZ gS fd ftyk Qksje dk vkns'k =qfViw.kZ gSA ftyk Qksje dks ;g ns[kuk Fkk fd vihykFkhZ@vukosnd dh // 10 // vksj ls izLrqr nLrkost izn'kZ vks- ih-&1 dh chek ikWfylh dh 'krZ dz-&4- 1 ds vuqlkj vihykFkhZ@vukosnd }kjk izFke ckj tkjh chek ikWfylh ds izkjaHk ds le; ;;fn chfer fdlh iwoZ O;kf/k] chekjh vFkok 'kkjhfjd voLFkk ftldh mlds }kjk chek ikWfylh ysrs le; Hkjs izLrko i=d esa ?kks"k.kk dh xbZ gks vFkok ugha] vkxkeh 04 o"kZ rd dh vof/k esa iz'uxr chek ikWfylh ds varxZr vkPNkfnr ugha gksxhA 'krZ dz-&4-1 esa Li"V mYysf[kr gS fd mDr 'krZ ds ykxw gksus ds fy, chek ikWfylh ds izFke ckj ykxw gksus dh frfFk ls rkRi;Z vihykFkhZ@vukosnd }kjk gh tkjh dh xbZ ikWfylh ls gksxkA mRrjoknh@ifjoknh }kjk viuh iwoZ ls vfLrRo esa jgh LokLF;xr fLFkfr ds ckjs esa iziksty QkeZ esa dksbZ mYys[k ugha fd;k Fkk ftl dkj.k ls vihykFkhZ@vukosnd }kjk chek ikWfylh ds lkFk layXu 'krZ dh 'krZ dz-&4-1 ds vuqlkj mRrjoknh@ifjoknh ds chekjh ds bZykt esa gq, [kpsZ ds isVs mRrjoknh@ifjoknh dks dksbZ Hkh jde vnk djus gsrq nkf;Rok/khu ugha FkhA vihykFkhZ@vukosnd chek daiuh }kjk mRrjoknh@ifjoknh ds nkos dk fujkdj.k djus ds iwoZ vius iSuy MkWDVj lR;thr lkgw ls Hkh vfHker eaxk;k x;k ftl ij muds }kjk fnukad&21-07-2008 dks esfMdy vfHker izLrqr fd;k x;k ftlds vuqlkj Hkh mRrjoknh@ifjoknh dh chekjh Pre-Existing gksus ds dkj.k vihykFkhZ@vukosnd] mRrjoknh@ifjoknh dks bZykt ds [kpsZ ds isVs dksbZ Hkh jde vnk djus gsrq nkf;Rok/khu ugha Fkh ftlds dkj.k vihykFkhZ@vukosnd }kjk vius i= fnukad&22-07-2008 ds }kjk mRrjoknh@ifjoknhds nkos dks fujLr dj lsok esa dksbZ deh ugha dh xbZ // 11 // gSA mRrjoknh@ifjoknh }kjk vius nkos ds fujLrhdj.k dh lwpuk izkIr gksus ds ckn iquZfopkj gsrq vihykFkhZ@vukosnd dks ,d i= fnukad&22- 08-2008 izsf"kr fd;k Fkk ftl ij vihykFkhZ@vukosnd }kjk ln~Hkkfod :Ik ls mlds nkos ds laca/k esa vUos"k.k djok;k x;k rFkk vius iSuy fpfdRld MkW- lR;thr lkgw ls iqu% vfHker eaxk;k x;kA vUos"k.k fjiksVZ fnukad&04-05-2009 rFkk iSuy MkW- lR;thr lkgw }kjk viuk vfHker fnukad&23-06-2009 esa iqu% bl ckr dk mYys[k fd;k x;k fd mRrjoknh@ifjoknh iwoZ ls gh Pre-Existing Disease ls ihfM+r Fkk blfy, mldk nkok ns; ugha gS] ftldh vuns[kh dj ftyk Qksje us fof/k ,oa rF; dh Hkwy dh gSA mRrjoknh@ifjoknh }kjk izLrqr nLrkost dzekad lh&9 ,oa lh&12 esa bl ckr dk mYys[k gS fd fnukad&15-05-2008 ds ikap o"kZ iwoZ ls gh mRrjoknh@ifjoknh dks dsykWbM uke chekjh Fkh ftldk mlds }kjk ikap o"kZ iwoZ gh LVsjkWbZM batsD'ku ysdj bZykt Hkh djok;k Fkk blfy, ftyk Qksje }kjk ;g fu"d"kZ fudkyk tkuk fd mRrjoknh@ifjoknh dks vius cka;s da/ks esa lwtu gksus ,oa mls igyh ckj dsykWbM ds :Ik esa igpku fd;s tkus dh tkudkjh fnukad&07-05-2008 dks MkW- dkyM+k ls tkap djok;s tkus ij gqbZ] iw.kZr% =qfViw.kZ gSA mRrjoknh@ifjoknh dh mDr dsykWbM chekjh gh MjesVªksQkbZczks lkjdksek izksV~;wcsjl uked chekjh esa rCnhy gks xbZ tks fd izFke ckj chek ikWfylh fy;s tkus ls chek ikWfylh ds e/; 04 o"kZ O;rhr uk gksus ds dkj.k viotZu DykWt dzekad&4-1 ds varxZr vkPNknu ifjf/k esa ugha vkrh Fkh] blfy, vihykFkhZ@vuosnd chek daiuh mRrjoknh@ifjoknh ds izfr // 12 // nkf;Rok/khu uk gksus ls mlds }kjk i= fnukad&02-07-2009 ds ek/;e ls nkok fujLr dj fn;k x;kA bl izdkj mRrjoknh@ifjoknh vihykFkhZ@vukosnd ls iz'uxr chek ikWfylh ysus ls iwo ls gh dsykWbM uked 'kkjhfjd O;kf/k ls ihfM+r Fkk ftldk fd mlds }kjk bZykt djk;k x;k Fkk] ijUrq mlds ckotwn mRrjoknh@ifjoknh }kjk mDr rF; dk mYys[k chek ikWfylh ysus ls iwoZ izLrqr izLrko&i=d esa mYys[k ugha fd;k x;k tks fd uk dsoy rkfRod rF;ksa dk lfdz; Nqiko dh Js.kh esa vkrk gS] cfYd iz'uxr chek ikWfylh ds viotZu DykWt dz-&4-1 ds varxZr vioftZr Hkh Fkk blfy, ftyk Qksje dks mRrjoknh@ifjoknh dk ifjokn fujLr dj nsuk Fkk] ijUrq ,slk uk dj ftyk Qksje }kjk rF; ,oa fof/k dh xaHkhj Hkwy dh gSA vr% vihykFkhZ@vukosnd dh vksj ls izLrqr vihy Lohdkj dh tkos vkSj ftyk Qksje }kjk ikfjr vkyksP; vkns'k vikLr dh tkosA 08- mRrjoknh@ifjoknh dh vksj ls milatkr gksus okys fo}ku vf/koDrk Jh uohu vkgwtk dk rdZ gS fd mRrjoknh@ifjoknh dk fnukad&24-05-2008 dks 'kY; fdz;k ds iwoZ mldk dHkh Hkh dksbZ vkWijs'ku ugha gqvk ,oa og lkekU; O;fDr dh rjg thou O;rhr dj jgs Fks] mUgsa dksbZ ?kkrd chekjh ugha FkhA mRrjoknh@ifjoknh }kjk fnukad&07-05- 2009 dks MkW- lquhy dkyM+k ls tkap djkbZ xbZ rc lwtu dks igyh ckj dsykWbM ds :Ik esa igpku dh xbZ vkSj iw.kZ larqf"V gsrq fnukad&15-05- 2008 dks MkW- yksds'k dqekj] bUnzizLFk viksyks gkWfLiVy ubZ fnYyh dks // 13 // fn[kk;k x;k rc mDr lwtu dks izFke n`"V;k dsykWbM crk;k x;k ,oa fof'k"V tkap ,oa igpku gsrq ck;ksIlh dh lykg nh xbZA ck;ksIlh dh fjiksVZ esa lwtu dks MjesVªksQkbZczks lkjdksek izksV~;wcsjl ik;k x;kA rnqijkar mRrjoknh@ifjoknh }kjk jktho xka/kh dSalj baLVhV~;wV ubZ fnYyh esa MkW- dfiy dqekj ls cka;s da/ks dh lwtu dh 'kY; fdz;k fnukad&24-05-2008 dks djkbZ xbZ vkSj mDr bZykt ds [kpsZ ds Hkqxrku gsr q vihykFkhZ@vukosnd ds le{k leLr nLrkost ,oa fcy fnukad&14-07- 2008 dks izLrqr fd;k x;k] fdUrq vihykFkhZ@vukosnd }kjk fnukad&22- 07-2008 dks fpfdRlk nkok bl vk/kkj ij fujLr dj fn;k x;k fd mRrjoknh@ifjoknh dks mDr chekjh fiNys 05 o"kksZa ls gS rFkk Pre- Existing Disease gksus ds dkj.k chek 'krksZa dk mYya?ku gS] fdUrq vihykFkhZ@vukosnd }kjk fnukad&07-05-2008 ds iwoZ dk ,slk dksbZ nLrkost izLrqr ugha fd;k x;k gS ftlls ;g fl} gks fd mRrjoknh@ifjoknh us dHkh Hkh mDr chekjh dk bZykt djok;k FkkA MkW- lquhy dkyM+k us viuh iphZ esa dgha Hkh dsykWbM ;k vU; fdlh chekjh dks 05 o"kZ iwoZ dk gksuk ugha crk;k gSA izFke ckj tkap fnukad&07-05- 2008 dks djkbZ xbZ Fkh fdUrq vihykFkhZ@vukosnd }kjk izFke tkap ds iwoZ dk dksbZ Hkh nLrkost izLrqr ugha fd;k x;k gS ftlls ;g izekf.kr gks fd mRrjoknh@ifjoknh dks ikWfylh ysus ds iwoZ Pre-Existing Disease FkhA MkW- yksds'k dqekj }kjk fnukad&15-05-2018 dks ¼,usD'pj lh&9½ lk¶V fV';w ljdksek vFkok dsykWbM ds :Ik esa iz'uokpd lwfpr fd;k gS rFkk ckW;ksIlh djkus dh lykg nh gSA mDr ckW;ksIlh VsLV dh fjiksVZ // 14 // fnukad&20-05-2008 }kjk mRrjoknh@ifjoknh dks izFke ckj irkk prk fd mRrjoknh@ifjoknh dks MjesVªksQkbZczks lkjdksek izksV~;wcsjl FkkA MkW- yksds'k dqekj us tkap iphZ fnukad&15-05-2008 ¼,usD'pj lh&9½ esa ;g Li"V fy[kk gS fd Repid Grow Since 8 Months. ftlls ;g fl} gksrk gS fd ikWfylh ysus ds Ik'pkr~ rFkk vkWijs'ku ds 6&8 ekg iwoZ ;g xkaB@lwtu gqbZ gSA mRrjoknh@ifjoknh }kjk chek 'krksZa dk mYya?ku ugha fd;k x;k gS rFkk mDr chekjh Pre-Existing Disease dh ifjf/k esa ugha vkrh gSA ftyk Qksje }kjk tks vkns'k ikfjr fd;k x;kgS og iw.kZr% mfpr gS vkSj mlesa fdlh izdkj ds gLr{ksi dh vko';drk ugha gSA vr% vihykFkhZ@vukosnd }kjk izLrqr vihy fujLr dh tkosA 09- geus mHk;i{kksa ds fo}ku vf/koDrkx.k dk rdZ Jo.k fd;k rFkk ftyk Qksje ds vfHkys[k ,oa vkyksP; vkns'k dk Hkh ifj'khyu fd;k x;kA 10- izdj.k esas ;g Lohd`r rF; gS fd mRrjoknh@ifjoknh }kjk fnukad&11-03-2006 dks vihykFkhZ@vukosnd ls esfMDyse ikWfylh izkIr dh xbZ Fkh tks dze'k% 11-03-2007 ,oa 11-03-2008 dks uohuhd`r dh xbZ FkhA mRrjoknh@ifjoknh }kjk esfMDyse nkok izLrqr fd;k x;k tks vihykFkhZ@vukosnd }kjk fnukad&22-07-2008 dks bl vk/kkj ij fujLr dj fn;k x;k fd mRrjoknh@ifjoknh chek ikWfylh ds vfLrRo esa vkus ls iwoZ ls gh Pre-Existing Disease ls ihfM+r Fkk tks fd ikWfylh ds viotZu DykWt dz-&4-1 gS ftlds vuqlkj vihykFkhZ@vukosnd mDr // 15 // chekjh ds bZykt ds isVs dksbZ Hkh jkf'k vnk djus gsrq nkf;Rok/khu ugha gSA 11- vihykFkhZ@vukosnd ds fo}ku vf/koDrk dk rdZ Fkk fd ftyk Qksje dks ;g Hkh ns[kuk Fkk fd iz'uxr chek ikWfylh dh /kkjk 4-1 esa ;g Hkh Li"V mYysf[kr gS fd mDr 'krZ ds ykxw gksus ds fy, chek ikWfylh ds izFke ckj ykxw gksus dh frfFk ls rkRi;Z bl fo:} i{kdkj }kjk gh tkjh dh xbZ ikWfylh ls gksxkA mDr /kkjk 4-1 dk 'kCn'k% fuEukuqlkj mYys[k fd;k tk jgk gS%& "4.1 Pre-Existing health condition or disease or ailment/injuries Any ailment/disease/injuries/health condition which are pre-existing (treated/untreated, declared/not declared in the proposal form) when the cover incepts for the first time are excluded up to 4 years of this policy being in force continuously. For the purpose of applying this condition, the date of inception of this Mediclaim policy taken form Oriental Insurance Company shall be considered, provided the renewals have been continuous and without any break in period.
This exclusion will also apply to any complications arising from pre-existing ailments/diseases/injuries. Such complications will be considered as a part of the pre-existing health condition or disease. To illustrate if a person is suffering from hypertension or diabetes or both hypertension and diabetes at the time of taking the policy, then policy shall be subject to following exclusions. Diabetes Hypertension Diabetes & Hypertension Diabetic Retinopathy Cerebro Vascular Diabetic Retinopathy accident Diabetic Hypertensive Diabetic Nephropathy Nephropathy Nephropathy Diabetic Foot/wound Internal Bleed Diabetic Foot Hemorrhages // 16 // Diabetic Angiopathy Coronary Artery Diabetic Angiopathy Disease Diabetic Neuropathy Diabetic/Neuropathy Hyper/Hypoglycemia Hyper/hypoglycemia shocks shocks Coronary Artery Disease Cerebro Vascular Accident Hypertension Nephropathy Internal Bleeds/Hemorrhages mRrjoknh@ifjoknh }kjk viuh iwoZ ls vfLrRo esa jgh LokLF;xr fLFkfr ds ckjs esa iziksty QkeZ tks fd izn'kZ vks- ih-&2 gS] esa dksbZ mYys[k ugha fd;k Fkk ftl dkj.k ls fo:} i{kdkj chek daiuh }kjk chek ikWfylh ds lkFk layXu 'krZ lacaf/kr nLrkostksa dh /kkjk&4-1 ds vuqlkj mRrjoknh@ifjoknh ds chekjh ds bZykt esa gq, [kpsZ ds isVs mRrjoknh@ifjoknh dks dksbZ Hkh jde vnk djus gsrq nkf;Rok/khu ugha FkhA 12- vc ;g ns[kuk gS fd D;k mRrjoknh@ifjoknh dks Pre-Existing Health Condition ;k chekjh Fkh tks chek ikWfylh ds viotZu dh dafMdk&4-1 ds varxZr vkrh Fkh\ 13- vihykFkhZ@vukosnd ds vfHkHkk"kd }kjk ;g rdZ fn;k x;k fd mRrjoknh@ifjoknh }kjk izLrqr nLrkostksa esa ls nLrkost dzekad&lh&9 ,oa 12 esa bl ckr dk Li"V mYys[k gS fd mDr nLrkost fnukad&15-05- // 17 // 2008 ds ikap o"kZ iwoZ ls gh mRrjoknh@ifjoknh dks dsykWbM uked chekjh Fkh ftldk mlds }kjk ikap o"kZ iwoZ gh LVsjkWbZM batsD'ku ysdj bZykt Hkh djok;k x;k Fkk blfy, ftyk Qksje }kjk ;g fu"d"kZ fudkyk tkuk fd mRrjoknh@ifjoknh dks vius cka;s da/ks esa lwtu gksus ,oa mlds igyh ckj dsykWbM ds :Ik esa igpku fd;s tkus dh tkudkjh fnukad&07- 05-2008 dks MkW- dkyM+k ls tkap djok;s tkus ij gqbZ] iw.kZr% =qfViw.kZ gSA 14- mRrjoknh@ifjoknh ds fo}ku vfHkHkk"kd }kjk ;g rdZ fn;k x;k fd mRrjoknh@ifjoknh dks fnukad&07-05-2008 ds iwoZ dksbZ chekjh ugha FkhA MkW- yksds'k dqekj }kjk fnukad&15-05-2008 ¼,usD'pj lh&9½ dks lk¶V fV';w ljdksek vFkok dsykWbM ds :Ik esa iz'u fpUg lwfpr fd;k gS rFkk ckW;ksIlh dj vkxs c<+us dh lykg nh xbZA bldk rkRi;Z ;g gS fd MkW- yksds'k dqekj tks ,d fo'ks"kK gSa] fcuk ckW;ksIlh ds fu'p;kRed ifj.kke rd ugha igaqp lds FksA VkVk eseksfj;y lsaVj eqacbZ esa mDr lwtu dh tkap djkbZ xbZ rc mDr lwtu dks dsykWbM ds uke ls tkuk x;k rFkk ckW;ksIlh djkus dh lykg nhA mDr fjiksVZ esa Vªksek Qkjesa'ku fiNys 05 o"kZ ls dgk x;kA mDr fjiksVZ esa chekjh dks dsykWbM ds :Ik esa igpkuh xbZ] fdUrq mDr fjiksVZ esa dgha Hkh vafdr ugha gS fd ;g dsykWbM fiNys 05 o"kksZa ls gSA mDr fjiksVZ esa Hkh ;g vafdr gS fd fiNys 08 eghus ls vkdkj esa o`f} gks jgh gSA mRrjoknh@ifjoknh dks fnukad&07- 05-2008 dks MkW- dkyM+k }kjk gh izFke ckj dsykWbM gksus dh laHkkouk O;Dr dh xbZ FkhA // 18 // 15- gekjs }kjk nLrkost izn'kZ lh&9 ,oa nLrkost izn'kZ lh&12 dk voyksdu fd;k x;kA nLrkost izn'kZ lh&9 bUnzizLFk viksyks gkWfLiVy dh iphZ gS ftlesa MkW- yksds'k dqekj }kjk Vªksek fiNys 05 o"kZ ls gksuk vafdr gSA mDr fjiksVZ esa dsykWbM ,oa lk¶V fV';w lkjdksek nksuksa ds lkeus iz'uokpd fpUg vafdr gS rFkk ckW;ksIlh djkus dh lykg nh xbZ gSA mRrjoknh@ifjoknh }kjk izLrqr nLrkost izn'kZ lh&12 VkVk eseksfj;y gkWfLiVy dh iphZ gS ftlesa Hkh Vªksek fiNys 05 o"kksZa ls gksuk vafdr gS rFkk MkW- vk'kh"k }kjk dsykWbM ds :Ik esa Mk;Xuksfll fd;k x;k tks fd fiNys 08 eghuksa ls vkdkj esa o`f} dj jgk FkkA mDr nksuksa nLrkost eas dgha Hkh dsykWbM dks fiNys 05 o"kksZa ls gksuk Li"V ugha gksrk gSA vr% vihykFkhZ@vukosnd ;g izekf.kr djus esa vlQy jgs gSa fd mRrjoknh@ifjoknh dks dsykWbM fiNys 05 o"kksZa ls Fkk ftldh tkudkjh mRrjoknh@ifjoknh dks FkhA 16- vihykFkhZ@vukosnd dh vksj ls ;g Hkh rdZ fn;k x;k fd mRrjoknh@ifjoknh dh mDr dsYkkWbM chekjh gh MjesVªksQkbczks lkjdksek izksV~;wcsjl ¼,d izdkj dk dSalj½ uked chekjh esa rCnhy gks xbZ tks fd vihykFkhZ@vukosnd ls izFke ckj chek ikWfylh fy, tkus ¼nLrkost dzekad&lh&5½ ls izn'kZ vks- ih-&1 dh chek ikWfylh ds e/; pkj o"kZ O;rhr uk gksus ds dkj.k viotZu DykWt dzekad&4-1 ds varxZr vkPNknu ifjf/k esa ugha vkrh FkhA blfy, vihykFkhZ@vukosnd chek daiuh] mRrjoknh@ifjoknh ds izfr nkf;rok/khu uk gksus ls mlds }kjk i= // 19 // fnukad&02-07-2009 ¼izn'kZ vks- ih-&9½ ds ek/;e ls nkok fujLr dj fn;k x;k tks fd lsok esa fuEurk dh Js.kh esa ugha vkrkA 17- mRrjoknh@ifjoknh }kjk ;g rdZ fn;k x;k fd mRrjoknh@ifjoknh }kjk lwpuk ds vf/kdkj ds rgr vUos"k.k fjiksVZ izkIr dh xbZ FkhA mDr fjiksVZ esa MkW- dfiy dqekj }kjk dkSfVY; buosLVhxs'ku ,tsalh dks i= ds tfj;s vfHker Hkstk x;k FkkA mDr vfHker esa MkW- dfiy dqekj }kjk ;g ugha fy[kk x;k gS fd mRrjoknh@ifjoknh dks foxr 05 o"kksZa ls dsykWbM Fkk tks fd MjesVªksQkbZczks lkjdksek izksV~;wcsjl esa cny x;k gksA vr% mRrjoknh@ifjoknh dk nkok esfMDyse viotZu dh dafMdk&4-1 ds varxZr ugha vkrk gSA 18- MkW- dfiy dqekj dk dkSfVY; buosLVhxs'ku ,tsalh dks fn;k x;k i= fnukad&18-03-2009 fuEukuqlkj gS%& "Certified that Mr. Vipin Singhania, from Raipur came to us with Seeking over Left Shoulder for 6-8 months. Which was finally diagnosed as Dermato Fibro Sarcoma Protuberause. Pre-existing keloid not cancerous condition whereas Dermato Fibro Sarcoma Protuberause is a melignant condition. Keloid can last for many years without any spread. Where as Dermato Fibro Sarcoma Protuberause increases in size in short time." 19- gekjs }kjk nLrkostksa dk voyksdu fd;k x;kA mDr nLrkostksa ds ifj'khyu ls Li"V gS fd ;fn mRrjoknh@ifjoknh dks Pre-Existing Disease gS rks Dyse 04 o"kZ O;rhr uk gksus ij ns; ugha gksxk] fdUrq mDr // 20 // izdj.k esa MkW- dfiy dqekj }kjk izsf"kr i= ¼nLrkost dz- lh&18½ esa ;g mYys[k ugha gS fd mRrjoknh@ifjoknh dks dsykWbM foxr 05 o"kksZa ls Fkk tks fd c<+rs gq, MjesVªksQkbZczks lkjdksek izksV~;wcsjl esa rCnhy gks x;k gSA MkW- lquhy dkyM+k ¼nLrkost dz- lh&8½] MkW- yksds'k dqekj ¼nLrkost dz- lh&9½ rFkk MkW- dfiy dqekj }kjk dsykWbM foxr 05 o"kksZa ls gksus ds laca/k esa dksbZ Hkh vfHker ugha fn;k x;k gSA izLrqr nLrkost ls izekf.kr gksrk gS fd mRrjoknh@ifjoknh dks ikWfylh ysus ds iwoZ dsykWbM ;k MjesVªksQkbZczks lkjdksek izksV~;wcsjl ugha Fkk vkSj uk gh ikWfylh ysus ds iwoZ bldk bZykt djk;k x;k Fkk rFkk MkW- }kjk Hkh viuh fjiksVZ esa fiNys 6&8 eghus esa lwtu@xkaB ds vkdkj esa o`f} gksus dk mYys[k fd;k gSA vihykFkhZ@vukosnd }kjk ,sls dksbZ Hkh nLrkost izLrqr ugha fd;s x;s gSa ftlls dsykWbM ;k MjesVªksQkbZczks lkjdksek izksV~;wcsjl dh tkudkjh ;k bZykt mRrjoknh@ifjoknh }kjk ikWfylh ysus ds iwoZ dh frfFk dk gksA mDr izdj.k esa mRrjoknh@ifjoknh ;g izekf.kr djus esa lQy jgk gS fd mRrjoknh@ifjoknh Pre-Existing Disease ds viotZu dh dafMdk&4- 1 ds varxZr ugha vkrk gS] vr% esfMDyse ikus dk vf/kdkjh gSA 20- mijksDr foospuk ds ifjizs{; esa ge bl fu"d"kZ ij igaqprs gSa fd mRrjoknh@ifjoknh ;g izekf.kr djus esa lQy jgk gS fd mRrjoknh@ifjoknh] chek ikWfylh ds viotZu dh dafMdk& 4-1 ds varxZr ugha vkrk gS rFkk esfMDyse ikus dk vf/kdkjh gSA ,slh fLFkfr esa chek daiuh }kjk esfMDyse dk nkok fujLr dj lsok esa deh dh gSA // 21 // ftyk Qksje }kjk vius vkns'k esa foospuk djrs gq, tks fu"d"kZ fudkyk gS og iw.kZr% mfpr gS mlesa fdlh izdkj dh vfu;ferk ,oa voS/kkfudrk ugha gS vkSj uk gh fdlh izdkj ds gLr{ksi dh vko';drk gSA 21- vr% vihykFkhZ@vukosnd dh vksj ls izLrqr vihy fujLr fd;s tkus ;ksX; gS] vr% fujLr dh tkrh gSA ftyk Qksje }kjk ikfjr vkyksP; vkns'k fnukad&29 ebZ 2019 dh iqf"V dh tkrh gSA bl vihy dk O;;
i{kdkj viuk&viuk ogu djsaxsA
¼ U;k;ewfrZ lh- ch- cktis;h ½ ¼Jherh :fp xks;y½
v/;{k lnL;k
04@10@2019 04@10@2019