State Consumer Disputes Redressal Commission
Apollo Munich Health Insurance Co.Ltd. ... vs Umesh Kumar Sethiya & Anr. on 20 June, 2017
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miHkksDrk fookn Áfrrks"k.k vk;ksx] iaMjh] jk;iqj vihy Øekad%FA/2017/216 lafLFkr fnukad: 06.04.2017 1- viksyks E;wfud gsYFk ba';ksjsal daiuh fyfeVsM] irk&10oka ekyk] Vkoj ch] fcfYMax ua-10] ch-,y-,Q- lkbcj flVh] Mh-,y-,Q-flVh] Qsl&2] xqM+xkao¼gfj;k.kk½ 122 002- ----------vihykFkhZ@vukosnd dz-1 2- viksyks E;wfud gsYFk ba';ksjsal daiuh fyfeVsM] irk&f}rh; ekyk] gyokfl;ka dkelZ gkÅl] 11] ,e-th-ekxZ] gtjr xat] y[kuż;w-ih-½ ----------vihykFkhZ@vukosnd dz-2 fo:) 1- mes'k dqekj lsfB;k] mez 42 o"kZ] firk Jh ds-,u-lsfB;k] fuoklh&¶ySV ua- 103] vk/kkjf'kyk VkWoj] eksok] jk;iqj] rglhy o ftyk jk;iqj¼N-x-½ -------mRrjoknh dz-1@ifjoknh 2- viksyks E;wfud gsYFk ba';ksjsal daiuh fyfeVsM] {ks=h; ,oa vf/kd`r vfHkdrkZ&Jherh 'osrk vxzoky] ifr Jh fodkl vxzoky] fuoklh&e-ua- 501@2 egkjk"Vª eaMy ds ikl] pkScs dkWyksuh] jk;iqj ftyk jk;iqj¼N-x-½ --------mRrjoknh dz-2@vukosnd dz-3 le{k% ekuuh; U;k;ewfrZ vkj-,l-'kekZ] v/;{k ekuuh; Jh Mh-ds-iksn~nkj] lnL;
ekuuh; Jh ujsUnz xqIrk] lnL;
i{kdkjksa ds vf/koDrk vihykFkhZx.k dh vksj ls Jh ,u-ds-Bkdqj] vf/koDrkA mRrjoknhx.k vuqifLFkrA vkns'k fnukad% 20@06@2017 }kjk%&ekuuh; Jh ujsUnz] xqIrk vihykFkhZ us ;g vihy /kkjk&15 miHkksDrk laj{k.k vf/kfu;e] 1986] ds varxZr ftyk miHkksDrk fookn izfrrks"k.k Qksje] jk;iqj¼N0x0½ // 2 // ¼ftls vkxs laf{kIr esa ^^ftyk Qksje** lacksf/kr fd;k tk,xk½ ds ifjokn izdj.k dzekad&14@2013 **mes'k dqekj lsfB;k fo:) viksyks E;wfud gsYFk ba';ksjsal daiuh fyfeVsM o vU;** esa ikfjr vkns'k fnukad& 09-01-2017 ftlds }kjk ifjoknh ds ifjokn dks vkaf'kd :i ls Lohdkj dj vknsf'kr fd;k x;k fd%& ¼v½ vukosnd dz-1 o 2 chek daiuh] ifjoknh dks ikWfylh ds rgr~ izkIr gksus okyh chek/ku dh jkf'k 2]00]000@&¼nks yk[k :i;s½ ifjokn fnukad 10-01-2013 ls vnk;xh fnukad rd 6 izfr'kr lk/kkj.k okf"kZd C;kt lfgr vnk djsaxsA ¼c½ vukosnd dz-1 o 2 chek daiuh] ifjoknh dks mijksDr d`R; ds dkj.k gqbZ ekufld d"V ds fy, 10]000@&¼nl gtkj :i;s½ vnk djsaxsA ¼l½ vukosnd dz-1 o 2] ifjoknh dks vf/koDrk 'kqYd rFkk okn O;; ds :i esa 2]000@&¼nks gtkj :i;s½ Hkh vnk djsaxsA ls nqf[kr gksdj izLrqr fd;k gSA 2- ifjoknh dk ifjokn ftyk Qksje ds le{k laf{kIr esa bl izdkj jgk gS fd ifjoknh] vukosndx.k ds vf/kd`r vfHkdrkZ 'osrk vxzoky }kjk chek ikWfylh lacaf/kr tkudkjh iznku fd;s tkus ij bZ-th-gsYFk baMhT;qoy LVS.MMZ ikWfylh gsrq 6]555-79@&¼N% gtkj ikap lkS ipiu :i;s mU;klh iSls½ izhfe;e dk Hkqxrku vius ifjokj dks LokLF; laca/kh lsokvksa ls lqj{kk iznku djus ds mn~ns'; ls fd;k x;kA vukosndx.k }kjk izhfe;e dh jkf'k izkIr djus ds i'pkr~ ifjoknh dks ikWfylh dzekad 110200@11001@1000222066 fnukad 20-07-2011 ds ek/;e ls ifjoknh] mudh iRuh o iq=h dks chekd`r fd;k x;k FkkA mDr ikWfylh fnukad 20- 07-2011 ls ysdj fnukad 19-07-2012 rd oS/k o izHkko'khy FkhA ifjoknh dks vukosndx.k }kjk mDr ikWfylh ds v/khu 5]00]000@&¼ikap yk[k :i;s½ rd chekd`r fd;k x;k FkkA bl izdkj ifjoknh ,oa mlds ifjokj // 3 // esa ls fdlh dks LokLF; laca/kh leL;k mRiUu gksus dh fLFkfr esa ifjoknh 5]00]000@&¼ikap yk[k :i;s½ rd nkok Hkqxrku izkIr djus dh ik=rk j[krk gSA ifjoknh dks vpkud LokLF; laca/kh leL;k mRiUu gqbZ ftldh tkap djk;s tkus ij Kkr gqvk fd mls jh<+ dh gM~Mh esa fodkj mRiUu gqvk gS] ftldk tYn ls tYn mfpr bykt u djk;s tkus dh fLFkfr esa xaHkhj 'kkjhfjd fodkj] ydok vkfn mRiUu gksus dh iw.kZ laHkkouk FkhA ifjoknh }kjk rRdky mipkj fd;s tkus ds mn~ns'; ls ckWEcs gkfLiVy ,aM esfMdy fjlpZ lsaVj esa laidZ lk/kk tgka fpfdRld Jh vjfoan th dqyd.khZ ds ekxZn'kZu esa mijksDr fodkj dk bykt djk;k x;kA ifjoknh mijksDr fodkj ds funku gsrq fnukad 11-06-2012 ls fnukad 14-06-2012 rd mijksDr vLirky esa HkrhZ jgkA ifjoknh dks mijksDr bykt esa yxHkx 2]61]334@&¼nks yk[k ,dlB gtkj rhu lkS pkSrhl :i;s½ dk O;; ogu djuk iM+k] ftldk iw.kZ Hkqxrku ifjoknh }kjk fd;k x;kA ifjoknh dks mijksDr jkf'k dh izkfIr dh ik=rk mijksDr ikWfylh ds v/khu izkIr Fkh ftlds vuq:i ifjoknh }kjk nkok Hkqxrku gsrq vkosnu vukosndx.k ds le{k izLrqr fd;k x;k FkkA ifjoknh ds mijksDr nkok Hkqxrku gsrq izLrqr vkosnu i= dks vukosndx.k }kjk i= fnukad 27-07- 2012 ds ek/;e ls vLohdkj dj fn;k x;kA ifjoknh }kjk fu;fer :i ls vukosndx.k ls laidZ lk/kdj mijksDr nkok jkf'k dh ekax fd;s tkus ds mijkar Hkh vkt fnukad rd vukosndx.k }kjk nkok jkf'k dk Hkqxrku ugha fd;k x;k gS tks fd ifjoknh ds lkFk vukosndx.k dh lsok esa fuEurk gSA vukosndx.k }kjk xyr tkudkfj;ka nsrs gq, mijksDr ikWfylh ifjoknh dks iznku dh xbZ gSA ifjoknh us bl laca/k esa nkok jkf'k dh ekax djrs gq, vius vf/koDrk ds ek/;e ls fnukad 31-10-2012 dks ,d fof/kd lwpuk i= izsf"kr fd;k tks vukosndx.k dks fnukad 03-11-2012 dks dks izkIr gks pqdk gS fdUrq vukosndx.k }kjk mDr lwpuk i= dk dksbZ tokc ugha fn;k x;k vkSj u gh nkok jkf'k dk Hkqxrku fd;k x;k // 4 // gSA vr% ifjoknh us mijksDr vk/kkj ij vius ifjokn i= ds dafMdk 26 esa of.kZr vuqlkj vuqrks"k fnyk;s tkus dk fuosnu fd;k gSA 3- ifjoknh }kjk ifjokn i= esa fd;s x;s vfHkdFku ds leFkZu esa Lo;a dk 'kiFk i= fnukafdr 10-01-2013 rFkk lwph vuqlkj nLrkostks dh QksVksizfr izLrqr fd;k gSA 4- vukosnd dz-1 o 2 }kjk ftyk Qksje ds le{k tokcnkok izLrqr dj vfHkopu fd;k x;k fd pwafd vukosnd dz-1 o 2 dk dksbZ 'kk[kk dk;kZy; ftyk Qksje jk;iqj ds {ks=kf/kdkj ds Hkhrj fLFkr ugha gS blfy;s bl izdj.k dh lquokbZ dk {ks=kf/kdkj ftyk Qksje jk;iqj dks ugha gSA dsoy ftyk Qksje y[kuÅ ;k ftyk Qksje xqM+xkao esa bl izdj.k dh lquokbZ dh {ks=kf/kdkfjrk j[krs gSaA vr% {ks=kf/kdkj ds vHkko esa izLrqr ifjokn fujLr fd;s tkus ;ksX; gSA vkxs vukosnd dz-1 o 2 }kjk vius tokcnkos esa ;g Hkh vfHkdFku fd;k gS fd ifjoknh dk mijksDr dk chek nkok ikWfylh viotZu ds 'krZ dzekad C ds vuqlkj Hkqxrku ;ksX; ugha gSA okLro esa ifjoknh }kjk tks ltZjh djokbZ xbZ Fkh og ikWfylh ysus ds nks o"kZ ds Hkhrj gh djokbZ xbZ Fkh tks ikfylh viotZu ds 'krZ dz- 6 C ds vuqlkj mDr ltZjh chek tksf[ke ls vkPNkfnr ugha FkhA ifjoknh ds }kjk chek ikfylh dh 'krksZ dk mYya?ku fd;k x;k gSA ,slh fLFkfr esa ifjoknh dksbZ Hkh jkf'k izkIr djus dk vf/kdkjh ugha gSA vukosnd dz-1 ,oa 2 }kjk lsok esa dksbZ fuEurk ugha dh xbZ gS vkSj u gh dksbZ O;olkf;d dnkpj.k fd;k x;k gSA mDr vk/kkj ij vukosnd dz-1 ,oa 2 }kjk ifjoknh ds ifjokn dks lO;; fujLr fd;s tkus dk fuosnu fd;k x;k gSA 5- vukosnd dz-1 o 2 dh vksj ls vius tokcnkos ds leFkZu esa Jh lehj HkVukxj okbl izslhMsaV yhxy dk 'kiFk i= fnukafdr 24-07-2013 rFkk lwph vuqlkj nLrkost dh QksVksizfr izLrqr fd;k x;k gSA // 5 // 6- vukosnd dz-3 }kjk ftyk Qksje ds le{k tokcnkok izLrqr dj vfHkopu fd;k x;k fd vukosnd dh fu;qfDr chek vf/kfu;e 1938 ds /kkjk&2¼10½ ds rgr~ fd;s x;s gSa tks bl izdkj gS%& (10) "Insurance Agent" means an insurance agent licensed under section 42 10[***] who receives of agrees to receive payment by way of commission or other remuneration in consideration of his solicting or procuring insurance business 11 [including business relating to the continuance, renewal or revival of policies of insurance], bl izdkj ;g Li"V gS fd bl vukosnd dh tokcnkjh /kkjk&2¼10½ ds rgr~ gSA Li"V gS fd ftlds rgr ifjoknh ds nkos dk fujkdj.k ugha vkrk gSA bl dkj.k ifjoknh }kjk izLrqr ifjokn mijksDr izkjafHkd vkifRr ds vk/kkj ij fujLr fd;s tkus ;ksX; gSA vukosnd dz-3 }kjk ;g Hkh vfHkdFku fd;k x;k fd ;g vukosnd fdlh Hkh izdkj ls ifjoknh dks nh tkus okyh lsok esa deh fd;s tkus ds ckcr~ tokcnkj ugha gSA bl vukosnd dk nkf;Ro dsoy ,d vfHkdrkZ dk gS ftlds vuqlkj ifjoknh ,oa vukosnd dz-1 o 2 rd lafonk tkjh djk nsus rd gh gSA chek ikWfylh tkjh gksus ds mijkar ifjoknh dk nkok chek ikWfylh ds 'krksZa ds v/khu ns; gksrk gSA bl izdkj izdj.k esa ifjoknh ds }kjk bl vukosnd dks fof/k ds fo:) i{kdkj cuk;k x;k gS] tks bl vukosnd ds fo:) iks"k.kh; ugha gSA bl vukosnd }kjk vukosnd dz-1 o 2 dh chek ikWfylh dk izLrko crkSj ,tsaV ifjoknh ds le{k j[kk gSA ifjoknh us chek ikWfylh ds 'krksZa dks i<+dj chek djk;k gSA ifjoknh us bl vukosnd ds ek/;e ls nkok Hkqxrku gsrq dksbZ nkok vukosnd ds le{k is'k ugha fd;k gSA bl vukosnd ls ifjoknh dk dksbZ laidZ ugha gSA bl vukosnd us chek ikWfylh crkSj vfHkdrkZ ifjoknh dks iznku dh gSA bl vukosnd dk ifjoknh ds nkos dks Lohdkj ;k vLohdkj fd;s tkus ls dksbZ laca/k ugha gSA ifjoknh dks bl vukosnd ds fo:) ifjokn izLrqr djus dk dksbZ okn dkj.k Hkh izkIr ugha gSA bl vukosnd dk ifjoknh ls // 6 // lsok iznkrk ,oa miHkksDrk dk laca/k ugha gSA ifjoknh dksbZ Hkh okafNr vuqrks"k bl vukosnd ls izkIr djus dk vf/kdkjh ugha gSA vr% vukosnd dz-3 }kjk ifjoknh }kjk izLrqr ifjokn fujLr fd;s tkus dk fuosnu fd;k x;k gSA 7- vukosnd dz-3 dh vksj ls vius tokcnkos ds leFkZu esa Jherh 'osrk vxzoky dk 'kiFk i= fnukafdr 10-09-2014 rFkk lwph vuqlkj nLrkost izLrqr fd;k x;k gSA 8- ftyk Qksje us mHk;i{kksa dh vksj ls izLrqr nLrkosth lk{;ksa ,oa 'kiFki=ksa ds ifj'khyu ds i'pkr~ ifjoknh dk ifjokn] ;g fu"d"kZ fudkyrs gq, fd vukosnd dz-1 o 2 chek daiuh] ifjoknh ds laca/k esa lsok esa fuEurk ,oa O;olkf;d dnkpj.k ds nks"kh gS] Lohdkj fd;k x;k] ftlds fo:) ;g vihy gSA 9- vihykFkhZx.k@vukosnd dz-1 o 2 dh vksj ls milatkr gksus okys fo}ku vf/koDrk Jh ,u-ds-Bkdqj }kjk rdZ fd;k x;k fd ftyk Qksje }kjk tks vkns'k ikfjr fd;k x;k gS og fof/k fo:) ,oa vuqfpr gSA ftyk Qksje }kjk ikWfylh viotZu ds 'krZ dzekad 6 lh dks /;ku esa yk;s fcuk tks {kfriwfrZ mRrjoknh dz-1@ifjoknh dks iznku dh gS og fof/k fo:) ,oa vuqfpr gSA mRrjoknh dz-1@ifjoknh bls izkIr djus ds vf/kdkjh ugha gSA okLro esa mRrjoknh dz-1@ifjoknh }kjk tks ltZjh djokbZ xbZ Fkh og pwafd ikWfylh ysus ds nks o"kZ ds Hkhrj djokbZ xbZ Fkh blfy;s mDr ltZjh chek tksf[ke ls vkPNkfnr ugha FkhA fQj Hkh ftyk Qksje }kjk mRrjoknh dz-1@ifjoknh dks mDr {kfriwfrZ dks iznku djus dk vkns'k fn;k x;k gSA vr% vihykFkhZx.k@vukosnd dz-1 o 2 dh vihy Lohdkj dh tk;s rFkk ftyk Qksje }kjk ikfjr vkns'k fujLr fd;k tk;sA // 7 // 10- tc ;g izdj.k vafre rdZ ds fy;s fy;k x;k ml le; mRrjoknh dz-1@ifjoknh] mRrjoknh dz-2@vukosnd dz-3 dh vksj ls dksbZ mifLFkr ugha gqvkA 11- geus mHk;i{k ds fo}ku vf/koDrk dk rdZ Jo.k fd;k rFkk ftyk Qksje ds vfHkys[k ,oa vkyksP; vkns'k dk Hkh ifj'khyu fd;kA 12- izLrqr izdj.k esa vihykFkhZx.k@vukosnd dz-1 o 2 }kjk vius tokcnkos dh dafMdk 12 esa ;g izfrj{kk yh gS fd pwafd vihykFkhZx.k@vukosnd dz-1 o 2 dk dksbZ 'kk[kk dk;kZy; ftyk Qksje jk;iqj ds {ks=kf/kdkj ds Hkhrj fLFkr ugha gS] blfy;s bl izdj.k dh lquokbZ dk {ks=kf/kdkj ftyk Qksje jk;iqj dks ugha gSA miHkksDrk laj{k.k vf/kfu;e dh /kkjk 11 ds vuqlkj flQZ ftyk Qksje y[kuÅ ;k ftyk Qksje xqM+xkao dks gh bl izdj.k dh lquokbZ dk {ks=kf/kdkfjrk izkIr gSA vr% izLrqr izdj.k izFke n`"V;k gh fujLr fd;s tkus ;ksX; gSA 13- pwafd ;g ,d fof/kd iz'u gS vkSj bldk laca/k izdj.k dh xzkg~rk ls gS blfy;s vihykFkhZx.k@vukosnd dz-1 o 2 dh bl vkifRr dk fujkdj.k loZizFke fd;k tkuk vko';d gSA gekjs }kjk izdj.k esa izLrqr nLrkostksa rFkk lk{;ksa dk ifj'khyu fd;k x;kA Lo;a vihykFkhZx.k@vukosnd dz-1 o 2 }kjk izdj.k esa chek daiuh rFkk mRrjoknh dz-1@ifjoknh }kjk gLrk{kfjr izLrkoi= dh QksVksizfr dks layXu fd;k x;k gS¼Annexure R-1½] bl izLrko i= ds var esa mRrjoknh dz-1@ifjoknh }kjk lgefr Lo:i gLrk{kj fd;s x;s gSaA ;g izLrkoi= jk;iqj esa fnukad 20-07-2011 dks gLrk{kfjr fd;s x;s gSa] ftlesa xokg ds :i esa mRrjoknh dz-2@vukosnd dz-3 }kjk tks vihykFkhZx.k@vukosnd dz-1 o 2 dh vfHkdrkZ gS gLrk{kj fd;s x;s gSaA izdj.k esa ;g Hkh vfookfnr gS fd mRrjoknh dz-1@ifjoknh }kjk tks chek izLrkod Hkh gS esfMDyse ikWfylh [kjhnus gsrq izhfe;e jkf'k dk Hkqxrku mRrjoknh dz-
// 8 // 2@vukosnd dz-3 dks jk;iqj esa gh fd;k x;kA ftls vihykFkhZx.k@vukosnd dz-1 o 2 dh rjQ ls mRrjoknh dz-2@vukosnd dz-3 }kjk izkIr fd;k x;k gSA gekjs erkuqlkj tc chek izLrko i= dk vuqca/k jk;iqj esa gLrk{kfjr gqvk rFkk chek izhfe;e dk Hkqxrku Hkh jk;iqj esa gh gqvk rc ;g ekuk tk;sxk fd okn dkj.k va'kr% ;k Hkkxr% jk;iqj esa mRiUu gqvkA ,slh fLFkfr esa fu'p; gh ftyk Qksje jk;iqj dks izLrqr izdj.k dh lquokbZ dh {ks=kf/kdkfjrk izkIr gSA ge ;gka vihykFkhZx.k@vukosnd dz-1 o 2 ds bl rdZ dks Lohdkj ;ksX; ugha ikrs gSa fd izLrqr izdj.k dh lquokbZ dk {ks=kf/kdkj ftyk Qksje jk;iqj dks ugha gSA 14- 2016(3) CPR 586(NC) Pukhrajdeep Singh & ors. Vs. Emaar MGF Lind Ltd. Decided on 01-09-2016 esa Hkh ekuuh; jk"Vªh; vk;ksx }kjk ;g vfHkfu/kkZfjr fd;k x;k gS fd%& ^^Complaint can be instituted in District Forum within local limits of whose jurisdiction cause of action whole or partly arises even if none of Opposite parties resides or carries on business within said jurisdiction. Complaint, in order to succeed in consumer Complaints filed by them had to prove booking of flats and payment of Earnest money to developer through its agent place where booking was made and place where payment was callcted from complainants constituted essential facts which complainants had to prove in order to succeed in consumer complaints filed by them state commission was not right in taking view that District Forum at Moga did not have territorial jurisdiction to entertain complaints."
mijksDr U;k;n`"Vkar esa ekuuh; jk"Vªh; vk;ksx }kjk Hkh ;gh vfHkfu/kkZfjr fd;k x;k gS fd ftl LFkku esa jkf'k dk Hkqxrku fd;k x;k gSA ogka ds ftyk Qksje dks lquokbZ dk {ks=kf/kdkj gSA 15- vc gesa bl rF; ij fopkj.k djuk gS fd D;k vihykFkhZx.k@vukosnd dz-1 o 2 }kjk mRrjoknh dz-1@ifjoknh ds // 9 // fpfdRldh; O;; ds Hkqxrku dks vLohdkj dj lsok esa fuEurk dh xbZ gS\ 16- vihykFkhZx.k@vukosnd dz-1 o 2 }kjk mRrjoknh dz-1@ifjoknh dks tks Claim Repudiation i= fn;k gS ¼nLrkost dz- Annexure 8½ og fuEukuqlkj gS%& "Without Prejudice"
Date: 27 Jul 2012 ^^To Umesh Kumar Sethia(9300219611) S/O K.N. Sethia, Flat No-103, Aadhar Sheela Tower Mowa, Raipur, Chhattisgarh-492001.
Claim Under Policy No. 110200/11001/1000222066 with Card No. 10002241624 Name of Insurer Apollo Munich Health Insurance Co. Ltd. Name of the Insured Person Umesh Kumar Sethia Calimed Amount: Rs. 261334/-
Claimed for: L4-L5 Herniated nucleus. Hospital Name: Bombay Hospital and Medical Research Centre Claim ID: 81984 Employee ID: Date of Admission: 11 Jun 2012 Date of Discharge: 14 Jun 2012 Received Date: 25 Jul 2012 Dear Mr./Ms. Umesh Kumar Sethia
We Have processed your claim with details and documents submitted to us and we regret to convey that the claim is not payable as it does not fall under the purview of the policy opted by the claimant for the following reasons:
The submitted claims is for the illness which has a specific two years of waiting period as per the policy and the policy start date is 20 Jul 2011, Hence we regret to inform you that your claim is repudiated under Section
6) c of the policy.
We have retained the claim papers for further references. In case you need further clarification or assistance Please refer the above ClaimID for any further correspondence you may write to us or send an email at [email protected] or speak with our 24 X 7 customer call center on 18004254080 quoting the claim reference no.
We are commited to serve you better for any other servies related to your policy.
// 10 // Yours Sincerely, Authorized Signatory In Case you are dissatisfied with our decision even after your request of reconsideration of the claim, you may approach the ombudsman in your territory."
bl i= ds ifj'khyu ls ;g Li"V gksrk gS fd vihykFkhZx.k@vukosnd dz-1 o 2 }kjk mRrjoknh dz-1@ifjoknh dk nkok bl vk/kkj ij fujLr fd;k gS fd ikWfylh viotZu ds 'krZ dzekad 6¼C½ ds vuqlkj mRrjoknh dz-1@ifjoknh }kjk tks ltZjh djkbZ xbZ gS] mldk tksf[ke ikfylh ysus ds 2 o"kZ ckn gh vkPNkfnr gksrk gS] tcfd mRrjoknh dz-1@ifjoknh dh ltZjh ikfylh ysus ds ,d o"kZ ds Hkhrj gqbZ gS] blfy;s nkok iznku ugha fd;k tk ldrk gSA 17- gekjs }kjk izdj.k esa izLrqr ikfylh 'krksZ dk voyksdu fd;k x;kA izdj.k esa mRrjoknh dz-1@ifjoknh }kjk rFkk vihykFkhZx.k@vukosnd dz-1 o 2 }kjk Hkh ikfylh 'krksZ dks izLrqr fd;k x;k gS¼nLrkost dzekad Annexure-1 ,oa nLrkost dz- R-2½A pwafd chek ikfylh mHk; i{kdkjksa }kjk gLrk{kfjr ,d vuqca/k gS blfy;s nksuksa gh i{kdkj ikfylh dh 'krksZ ls caf/kr gksrs gSA geus ikfylh viotZu dh 'krZ dzekad 6(C) dk ifj'khyu fd;k ;g 'krZ fuEukuqlkj gS%& Section 6 Exclusions Specific Waiting Periods
c) The Illnesses and treatments listed below will be covered subject to a waiting period of 2 years as long as in the third Policy Year the Insured Person has been insured under an Easy Health Policy continuously and without any break:
i) Illnesses: arthritis if non infective; calculus diseases of gall bladder and urogenital system; cataract; fissure/fistula in anus, hemorrhoids, pilonidal sinus, gastric and duodenal ulcers; gout and rheumatism internal tumors, cysts, nodules, polyps including breast lumps (each of any kind unless malignant); osteoarthritis ans // 11 // osteoporosis if age related; polycystic ovarian diseases; sinusitis and related disorders and skin tumors unless malignant.
ii) Treatments: benign ear, nose and throat (ENT) disorders and surgeries (including but not limited to adenoidectomy, mastoidectomy, tonsillectomy and tympanoplasty); dilatation and curettage (D & C); hysterectomy for menorrhagia or fibromyoma or proplapse of uterus unless necessitated by malignancy; joint replacement; myomectomy for fibroids; surgery of gallbladder and bile duct unless necessitated by malignancy; surgery of genito urinary system unless necessitated by malignancy; surgery of benign prostatic hypertrophy; surgery of hernia; surgery of hydrocele;
surgery for prolapsed inter vertebral disk; surgery of varicose veins andvaricose uncers; surgery on tonsils and sinuses.'' 18- mRrjoknh dz-1@ifjoknh }kjk vihykFkhZx.k@vukosnd dz-1 o 2 ls Easy Health Individual standard ikfylh fnukad 20-07-2011 dks yh xbZ Fkh] ftldk ikfylh dzekad 11200@11001@1000222066 FkkA ikfylh vof/k fnukad 20-07-2011 ls fnukad 19-07-2012 Fkh rFkk bl ikfylh esa mRrjoknh dz-1@ifjoknh dk 2]00]000@&¼nks yk[k :i;s½ dk chek] mRrjoknh dz-1@ifjoknh dh iRuh Jherh lqferk lsfB;k dk 2]00]000@&¼nks yk[k :i;s½ dk chek rFkk mRrjoknh dz-1@ifjoknh dh iq=h dq- eqLdku lsfB;k dk 1]00]000@&¼,d yk[k :i;s½ dk chek FkkA ckEcs gkfLiVy ds fjdkMZ ds vuqlkj mRrjoknh dz-1@ifjoknh dk bZykt ckEcs gkfLiVy esa fnukad 11-06-2012 ls 14-06-2012 esa gqvk vFkkZr~ mRrjoknh dz-1@ifjoknh dk bZykt ikfylh ysus ds 2 o"kZ ds Hkhrj gqvk tks viotZu dh 'krZ dzekad 6(C) ds vuqlkj ches ls vkPNkfnr ugha FkkA 19- 2017(2) CPR 508(NC) M/s. R.R. Leather products Pvt. Ltd. Vs. Royal sundaram General Ins. Co. Ltd. & ors. Decided on 21-04-2017 esa ekuuh; jk"Vªh; vk;ksx }kjk ;g vfHkfu/kkZfjr fd;k x;k gS%& // 12 // 5- ^^It is not in dispute that on receipt of the insurnace policy for the period form 31.3.2014 to 30.3.2015 which contained the Basement Warranty Exclusion Clause, the complainant did not write any letter to the insurer protesting against the said clause and rejecting the insurance policy on account of the aforesaid the clause, being included there in. If the addition of the Basement Warranty Exclusion clause, was not acceptable to the complainant it ought to have informed the insurer accordingly and requested it either to delet the aforesaid Exclusion Clause from the policy or to refund the premium received from it, After taking refund from the insurer, the complainant could have looked for an insurer which was ready to give a policy withiout Basement Warranty Exclusion Clause, or could have approached IRDA for appropriate directions to the insurer, that having not been done, the obvious inference is that the complainant had accepted the basement warranty exclusion clause added by the insurer in the insurance policy fo the period from 13.3.2014 to 30.3.2015.
7. Since the alleged loss to the complainant took place in the basement of the building and the said loss was not covered on account of the Basement Warranty Exclusion Clause contained in the insurance policy, the complainant is not entitled to any reimbursement form the insurer for the said loss, The complaint, being devoid of any merit, is therefore dismissed, with no order as to costs."
20- 2017(2) CPR 618(NC) Ajit santok chand surana Vs. National Insurance Co. Ltd. Decided on 04-05-2017 esa ekuuh; jk"Vªh; vk;ksx }kjk ;g vfHkfu/kkZfjr fd;k x;k gS "Insurance Claim cannot be allowed ignoring exclusion clause"A 21- vc gesa ;g ns[kuk gS fd vihykFkhZx.k@vukosnd dz-1 o 2 }kjk ftl ltZjh ds vk/kkj ij mRrjoknh dz-1@ifjoknh dk chek nkok fujLr fd;k] D;k mRrjoknh dz-1@ifjoknh }kjk ckEcs gkfLiVy esa ogha ltZjh djokbZ xbZ FkhA vihykFkhZx.k@vukosnd dz-1 o 2 }kjk "Surgery for prolapsed inter vertebral disk" ds vk/kkj ij mRrjoknh dz-1@ifjoknh dk nkok fujLr fd;k x;k FkkA ckEcs gkfLiVy dh fMLpktZ lejh esa tks Final Diagnosis mYysf[kr dh xbZ gS oks "L4-L5 Herneated Nucleus // 13 // pulposus" gSA mRrjoknh dz-1@ifjoknh dks jh<+ dh gM~Mh ¼LikbZu½ laca/kh fodkj gqvk FkkA ftldk bZykt ckEcs gkfLiVy ds MkW- vjfoan th- dqyd.khZ }kjk] "Microendoscopic Disectomy ltZjh }kjk fd;k x;kA gekjs erkuqlkj mRrjoknh dz-1@ifjoknh dh mijksDr ltZjh ikfylh viotZu dh 'krZ dzekad 6(C) esa of.kZr "Surgery for prolapsed inter vertebral disk" esa vkrh gS vr% ge ;gka vihykFkhZx.k@vukosnd dz-1 o 2 ds bl rdZ dks Lohdkj ;ksX; ikrs gSa fd pwafd mRrjoknh dz- 1@ifjoknh dh mDr ltZjh ikfylh viotZu dh 'krZ dzekad 6(C) ds vuqlkj chfer ugha Fkh blfy;s mRrjoknh dz-1@ifjoknh ds nkos dks vLohdkj dj vihykFkhZx.k@vukosnd dz-1 o 2 }kjk lsok esa dksbZ fuEurk ugha dh xbZ gSA mijksDr U;k;n`"Vkarksa esa Hkh ekuuh; jk"Vªh; vk;ksx }kjk ;gh vfHkfu/kkZfjr fd;k x;k gS fd ikfylh dh viotZu 'krksZ ds vuqlkj gh cheknkos dk fujkdj.k fd;k tkuk mfpr gSA ftyk Qksje }kjk vius vkns'k dh dafMdk 13 esa tks fu"d"kZ fudkyk gS og iw.kZr% fof/k fo:) rFkk vuqfpr gSA rFkk fLFkj j[ks tkus ;ksX; ugha gSA 22- vc gesa ;g ns[kuk gS fd D;k mRrjoknh dz-2@vukosnd dz-3 tks vihykFkhZx.k@vukosnd dz-1 o 2 dk vfHkdrkZ gS] izdj.k esa nkf;Rok/khu gSA 23- 2016(2) CPR 227(NC) G.Krishna Kumar & anr. Vs. Har Auto Pvt. Ltd. & ors. esa ekuuh; jk"Vªh; vk;ksx }kjk ;g vfHkfu/kkZfjr fd;k x;k gS "Principal is liable for acts of its agent"A 24- mRrjoknh dz-2@vukosnd dz-3 }kjk tks ifjoknhx.k dk chek fd;k x;k rFkk izhfe;e Lohdkj fd;k x;k og d`R; vihykFkhZx.k@vukosnd dz-1 o 2 ds vfHkdrkZ ds :i esa fd;k x;k vkSj mijksDr U;k;n`"Vkar ds vuqlkj vfHkdrkZ ds dk;ksZ ds fy;s pwafd eq[;
// 14 // fu;ksDrk ¼Principal½ gh mRrjnk;h gksrk gS vr% gekjs erkuqlkj mRrjoknh dz-2@vukosnd dz-3 dh izdj.k esa dksbZ ftEesnkjh ugha curh gSA blfy;s izLrqr izdj.k esa mRrjoknh dz-2@vukosnd dz-3 ds fo:) ifjokn la/kkj.kh; ugha gSA 25- mijksDr foospuk ds ifjisz{; esa ge bl fu"d"kZ ij igqaprs gSa fd ftyk Qksje }kjk ikfjr vkyksP; vkns'k fLFkj j[ks tkus ;ksX; ugha gS vkSj [email protected] fdlh izdkj dh {kfriwfrZ ikus ds vf/kdkkjh ugha gSA 26- vr% ;g vkns'k ikfjr fd;k tkrk gS fd vihykFkhZx.k@vukosnd dz-1 o 2@chek daiuh dh vihy Lohdkj fd;s tkus ;ksX; gSA vr% Lohdkj dh tkrh gSA ftyk Qksje }kjk ikfjr vkyksP; vkns'k fnukad 09-01-2017 vikLr fd;k tkrk gSA QyLo:i ifjokn fujLr fd;k tkrk gSA vihy O;; ds laca/k esa dksbZ vkns'k ugha fn;k tk jgk gSA ¼U;k;ewfrZ vkj-,l- 'kekkZ½ ¼Mh-ds-iksn~nkj½ ¼ujsUnz xqIrk½ v/;{k lnL; lnL;
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