State Consumer Disputes Redressal Commission
Hdfc Ergo General Insurance Co.Ltd. vs Smt.Vibha Dixit & Anr. on 24 July, 2018
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ds :i esa 2]000@&¼nks gtkj :i;s½ dk Hkqxrku djsaxsA ls nqf[kr gksdj izLrqr fd;k x;k gSA 2- ifjoknh dk ifjokn ftyk Qksje ds le{k laf{kIr esa bl izdkj jgk gS fd vukosnd dz-2 }kjk vukosnd dz-1 ds ek/;e ls tujy ba';ksjsal ikfylh fodz; djus dk dkjksckj 'kgj jktukanxkao esa fd;k tkrk gSA ifjokfnuh ds ifr Jh iz'kkar nhf{kr }kjk izLrko i= ,oa vukosndx.k }kjk pkgs x;s nLrkost ,oa LokLF; ijh{k.k fjiksVZ iznku djus gq, fnukad 25-03-2016 ls fnukad 24-03-2017 rd dh vof/k ds fy, QSesyh Q~yksVj ds rgr gsYFk lqj{kk ikfylh flYoj Iyku fu/kkZfjr izhfe;e jkf'k 9]578@&¼ukS gtkj ikap lkS vB~gRrj ½ vukosnd dz-1 ,p- Mh-,Q-lh- cSad jktukanxkao dks fn;k tkdj ikfylh izksMDV dz; fd;k x;k] mDr ikfylh ds rgr chfer O;fDr iz'kkar nhf{kr Jherh foHkk // 3 // nhf{kr] vfo'kh ,oa vuqJh jgs gSA mHk;i{kksa dh larqf"V mijkar ikfylh dzekad 2952201023677801000 dk chekadu fd;k x;kA vukosndx.k }kjk mDr ikfylh ds rgr lHkh izdkj dh chekfj;ksa ds fy, ifjokfnuh ds laiw.kZ ifjokj ds lnL;ksa dks chfer gksuk tkfgj fd;k x;kA ifjokfnuh ds ifr dks izLrko i= Lohdkj fd;s tkus ds volj ij vFkok ikfylh 'ksM~;wy tkjh djus ds volj ij ikfylh 'krksZ ls voxr ugha djk;k x;kA ifjokfnuh ds ifr }kjk foxr nks o"kksZ ls ikfylh dz; dh tk jgh gSA iz'uk/khu ikfylh f}rh; ikfylh gS] ifjokfnuh izLrko i= nkf[ky djus ds rkjh[k ij lHkh chekfj;ksa ls eqDr jgh gSA ifjokfnuh dk LokLF; fnukad 01-05-2016 dks vuk;l [kjkc gksus ds dkj.k ifjokfnuh }kjk fpfdRld ls ijke'kZ fy;k x;kA fnukad 31-05-2016 dks vYVªklkmaM Qkj iSfYod djok;k x;k ftldh fjiksVZ esa ;wVªl esa flLV gksuk crk;k x;k chekjh ds funku ds fy, ySizksLdksfid ltZjh laca/kh fu.kZ; fy;k x;kA fnukad 07-06-2016 dks ifjokfnuh dk vkijs'ku fd;k x;kA ifjokfnuh ds ifr }kjk lacaf/kr ikfylh ij tkjh dS'kysl dkMZ dh izfdz;k ls lacaf/kr vkSipkfjdrk viksyks gkfLiVy fcykliqj esa djok nh x;h fdarq ifjokfnuh ds ifr ds eksckbZy ij chek daiuh }kjk eSlst fd;k x;k fd ifjokfnuh ds chekjh ij Dyse dk Hkqxrku chek daiuh }kjk ugha fd;k tk;sxkA ifjokfnuh dh Dyse fjDosLV dks vLohdkj djus dk vk/kkj ikfylh 'krZ dzekad 9 , ii b ds rgr ifjokfnuh dks gqbZ chekjh ds fy, nkok Hkqxrku ds fy, nks o"kZ dk osfVax ihfj;sM gksus ls vLohdkj fd;k x;k gSA ifjokfnuh ds chekjh ij yk;k x;k nkok iw.kZr% Hkqxrku ;ksX; jgk gS fdarq vukosnd }kjk O;olkf;d nqjkpj.k dj ifjokfnuh ds izfr mis{kk ,oa ykijokgh cjrh x;h gS tks fd lsok esa deh dh Js.kh esa vkrk gSA vr% ifjokfnuh }kjk vukosndx.k dh bl lsok esa deh ds fy;s vius ifjokn i= dh dafMdk 10 esa of.kZr vuqlkj vuqrks"k fnyk;s tkus dk fuosnu fd;k gSA // 4 // 3- ifjokfnuh }kjk ifjokn i= esa fd;s x;s vfHkdFku ds leFkZu esa Loa; dk 'kiFk i= fnukafdr 24-01-2017 ,oa lwph vuqlkj nLrkostks dh QksVksizfr izLrqr fd;k gSA 4- izdj.k esa vukosnd dz-1 vuqifLFkr jgs] muds fo:) ,di{kh; dk;Zokgh dh xbZ gSA vukosnd dz-1 }kjk vfHkopu] lk{; ,oa nLrkost izLrqr ugha fd;k x;k gSA 5- vukosnd dz-2 }kjk ftyk Qksje ds le{k tokcnkok izLrqr dj vfHkopu fd;k x;k fd chek ikfylh dh 'krZ ds rgr nks o"kZ dh vof/k lekfIr ls iwoZ mijksDr ltZjh chek ikfylh ds varxZr lfEefyr ugha gS vkSj ifjokfnuh dk nkok chek ikfylh ds fu;eksa o 'krksZ ds rgr fujLr fd;k x;k gSA ifjokfnuh vLirky esa fnukad 07-06-2016 dks bZykt gsrq HkrhZ gqbZ Fkh vkSj izFke chek dh ikfylh fnukad 25-03-2015 dks izkjaHk gqbZ bl izdkj chek 'krZ ds vuqlkj nks o"kZ dh vof/k iw.kZ uk gksus ls chek ikfylh dqN chekfj;ksa ds ykHk ls vkPNkfnr ugha FkhA ifjokfnuh ds nkos dk fujkdj.k miyC/k nLrkostksa ds vk/kkj ij fd;k x;k gSA ifjokfnuh dk nkok iw.kZr% ;ksX; ugha Fkk] Hkqxrku dh x;h fdlh Hkh jkf'k dh vnk;xh ds fy, vukosnd ftEesnkj ugha gS] D;ksafd D;ksafd chek ikfylh dh 'krZ ds vuqlkj nks o"kZ bartkj dh vof/k gSA ifjokfnuh miHkksDrk ugha gS vkSj u gh dksbZ Hkh jkf'k ;k mldk Hkkx izkIr djus dh vf/kdkfj.kh gSA ftyk Qksje dks ifjokfnuh ds ifjokn dks lquokbZ dk {ks=kf/kdkj ugha gSA ifjokfnuh ds }kjk izLrqr 'kiFk i= vkSipkfjd izd`fr dk gS ftlds dFku lk{; ls lefFkZr ugha gSA vr% vukosnd dz-2 }kjk ifjokfnuh ds ifjokn dks lO;; fujLr fd;s tkus dk fuosnu fd;k x;k gSA // 5 // 6- vukosnd dz-2 }kjk vius tokcnkok ds leFkZu esa ftyk Qksje ds le{k Jh jkgwy Jaxkjiqjs] ,fDthD;wfVo fyxy ,p-Mh-,Q-lh- bjxks tu-ba- da-fy- dk 'kiFk i= fnukafdr 01-05-2017 dk izLrqr fd;k x;k gSA 7- ftyk Qksje }kjk mHk;i{kksa dh vksj ls izLrqr nLrkosth lk{;ksa ,oa 'kiFki=ksa ds ifj'khyu ds i'pkr~ ifjokfnuh dk ifjokn] ;g fu"d"kZ fudkyrs gq, fd ifjokfnuh viuk ifjokn izekf.kr djus esa lQy jgh gS] Lohdkj fd;k x;k] ftlds fo:) ;g vihy gSA 8- vihykFkhZ@vukosnd dz-2 dh vksj ls milatkr gksus okys fo}ku vf/koDrk Jh eukst izlkn dk rdZ gS fd mRrjoknh dz-1@ifjokfnuh }kjk tks ;g vfHkopu fd;k x;k gS fd mRrjoknh dz-1@ifjokfnuh dks vukosndx.k }kjk ikfylh 'krsZ iznku ugha dh xbZ iw.kZr;k vlR; gSA mRrjoknh dz-1@ifjokfnuh }kjk nwljs o"kZ Hkh ikfylh dk fjU;qvy djk;k x;k FkkA mRrjoknh dz-1@ifjokfnuh }kjk dHkh Hkh vukosndx.k ds le{k ;g dFku ugha fd;k x;k fd mRrjoknh dz-1@ifjokfnuh dks ikfylh 'krZs iznku ugha dh xbZ gSa blls ;g izekf.kr gksrk gS fd mRrjoknh dz-1@ifjokfnuh dks ikfylh 'krksZ dh tkudkjh Fkh rHkh ikfylh dks nwljs o"kZ Hkh fjU;woy djk;k x;k FkkA ftyk Qksje }kjk cxSj rF;ksa ij /;ku fn;s tks vkns'k ikfjr fd;k gS og =qfViw.kZ gSA vr% vf/koDrk }kjk mijksDr vk/kkj ij vihykFkhZ @vukosnd dz-2 dh vihy dks Lohdkj fd;s tkus ,oa ftyk Qksje }kjk ikfjr vkns'k dks vikLr fd;s tkus dk fuosnu fd;k x;k gSA 9- mRrjoknh dz-1@ifjokfnuh dh vksj ls milatkr gksus okys fo}ku vf/koDrk vkj-ds-Hkkoukuh }kjk }kjk ftyk Qksje ds vkns'k dks U;k;ksfpr vkns'k fu:fir djrs gq, mls ;Fkkor cuk;s j[kus ,oa vihykFkhZ@vukosnd dz-2 dh vihy fujLr fd;s tkus dk fuosnu fd;k x;k gSA // 6 // 10- mRrjoknh dz-2@vukosnd dz-1 dh vksj ls milatkr gksus okys fo}ku vf/koDrk Jh ,l eaMy dk rdZ gS fd ftyk Qksje dk vkns'k =qfViw.kZ gS vr% vikLr fd;k tk;sA 11- geus mHk;i{k ds fo}ku vf/koDrkvksa dk rdZ Jo.k fd;k rFkk ftyk Qksje ds vfHkys[k ,oa vkyksP; vkns'k dk Hkh ifj'khyu fd;kA 12- izdj.k ds U;k;ksfpr fujkdj.k gsrq gesa bl iz'u ij fopkj.k djuk gS fd D;k vukosndx.k }kjk mRrjoknh dz-1@ifjokfnuh ds esfMDyse ds nkos dks fujLr dj lsok esa fuEurk dh gS\ 13- vukosndx.k ds ifjokn dks ftyk Qksje }kjk iwoZ esa fnukad 02-03-2017 ,oa 07-04-2017 ftlds }kjk fnukad 02-03-2017 dks vihykFkhZ@vukosnd dz-2 ds fo:) ,di{kh; dk;Zokgh dh xbZ Fkh vkSj fnukad 07-04-2017 dks vihykFkhZ@vukosnd dz-2 }kjk izLrqr vkosnu i= tks ,di{kh; dk;Zokgh fujLr fd;s tkus gsrq izLrqr fd;k x;k FkkA og ftyk Qksje }kjk fujLr fd;k x;k FkkA ftlds fo:) vihy dh xbZ Fkh o jkT; vk;ksx }kjk vihy dzekad FA/2017/393 esa fnukad 02-08-2017 dks vkns'k ikfjr djrs gq, ;g funsZ'k fn;k x;k Fkk fd vihykFkhZ@vukosnd dz-2] ifjokfnuh dks 3]000@&:-¼rhu gtkj :i;s½ ifjO;; dh jkf'k tek djus ds mijkar ftyk Qksje vihykFkhZ@vukosnd dz-2 dks fyf[kr dFku ,oa nLrkost izLrqr djus dk volj iznku djsaxsA vihykFkhZ@vukosnd dz-2 ftyk Qksje }kjk fn;s x;s frfFk ij vko';d :i ls fyf[kr dFku izLrqr djsaxsA mlds i'pkr~ ftyk Qksje mHk;i{kksa dks lquokbZ dk leqfpr volj iznku dj fof/kor vkns'k ikfjr djsaxsA rnkuqlkj ftyk Qksje }kjk vihykFkhZ@vukosnd dz-2 ds ifjokn dk fujkdj.k vkns'k fnukad 23-12-2017 dks fd;k x;kA ftlds fo:) ;g vihy gSA // 7 // 14- vukosndx.k }kjk loZizFke vius tokcnkos esa ;g izkjafHkd vkifRr yh gS fd izLrqr ifjokn i= lquokbZ dk {ks=kf/kdkj ftyk Qksje jktukanxkao dks ugha gSA vihykFkhZ@vukosnd dz-2 chek daiuh dh dksbZ Hkh 'kk[kk ftyk Qksje jktukanxkao dh lquokbZ ds {ks=kf/kdkj esa ugha gS vr% {ks=kf/kdkj ds vHkko esa mRrjoknh dz-1@ifjokfnuh dk ifjokn fujLruh; gSA ge vukosndx.k ds bl rdZ dks Lohdk;Z ugha ikrs gSaA izdj.k ds voyksdu ls ;g fofnr gksrk gS fd vukosnd dz-1 ,p-Mh-,Q- lh- cSad dk VkbZvi vukosnd dz-2 ,p-Mh-,Q-lh- bxksZ tujy ba';ksjsal daiuh ls gS vkSj vukosnd dz-2 vukosnd dz-1 ds fy;s ,tsaV ds :i esa dk;Z dj jgk gSA ifjokfnuh ds ifr }kjk vukosnd dz-2 chek daiuh ls QSfeyh ¶yksVj ds rgr gsYFk lqj{kk ikfylh flYoj Iyku fu/kkZfjr izhfe;e jkf'k 9]578@&:-¼ukS gtkj ikap lkS vB~gRrj :i;s½ mRrjoknh dz-2@vukosnd dz-1 ,p-Mh-,Q-lh- caSd jktukanxkoa esa tek fd;k FkkA bl rjg blls ;g izekf.kr gksrk gS fd mRrjoknh dz-2@vukosnd dz-1 ,p-Mh-,Q-lh- cSad ds }kjk mRrjoknh dz-1@ifjokfnuh ds ifr ls izhfe;e jkf'k jktukanxkao esa Lohdkj dh xbZ Fkh ,oa mRrjoknh dz-2@vukosnd dz-1@cSad vihykFkhZ@vukosnd dz-2@chek daiuh ds ,tsaV ds :i esa VkbZvi ds QyLo:i dk;Zjr gSA ,slh fLFkfr esa fu'p; gh ftyk Qksje jktukanxkao dks izdj.k dh lquokbZ dk {ks=kf/kdkj izkIr gSA 15- mRrjoknh dz-1@ifjokfnuh }kjk vius ifjokn i= esa ;g vfHkopu fd;k gS fd mRrjoknh dz-1@ifjokfnuh ds ifr }kjk vukosndx.k ls QSfeyh ¶yksVj ds rgr gsYFk lqj{kk ikfylh flYoj Iyku fu/kkZfjr izhfe;e jkf'k 9]578@&:-¼ukS gtkj ikap lkS vB~gRrj :i;s½ dk Hkqxrku dj dz; fd;k FkkA bl ikfylh dk ikfylh dz- 2952201023677801000 gSA mDr ikfylh ds rgr lHkh izdkj dh chekfj;ksa ds fy;s mRrjoknh dz- 1@ifjokfnuh ds laiw.kZ ifjokj ds lnL;ks dks chfer fd;k x;k FkkA ifjokfnuh ds ifr dks ikfylh 'ksM~;wy tkjh djus ds ckn ikfylh 'krksZ // 8 // ls voxr ugha djk;k x;k Fkk tcfd mRrjoknh dz-1@ifjokfnuh ds ifr }kjk foxr nks o"kksZ ls fu;fer :i ls ikfylh dz; dh tk jgh gSA iz'uk/khu ikfylh f}rh; ikfylh gSA vkxs mRrjoknh dz-1@ifjokfnuh }kjk ;g vfHkopu fd;k x;k gS fd mRrjoknh dz-1@ifjokfnuh dks isV dh leL;k gksus ij mRrjoknh dz-1@ifjokfnuh }kjk fnukad 02-06-2016 dks fpfdRld ls laidZ fd;kA fpfdRld }kjk vYVªklkÅaM djkus ij mRrjoknh dz-1@ifjokfnuh dks ;g crk;k x;k fd mRrjoknh dz- 1@ifjokfnuh ds ;wVªl esa flLV gS rFkk chekjh ds funku ds fy;s ltZjh djkuk vko';d gSA blds ckn mRrjoknh dz-1@ifjokfnuh }kjk fnukad 07-06-2016 dks flLV dk vkWijs'ku djk;k x;kA vkijs'ku ds ckn mRrjoknh dz-1@ifjokfnuh }kjk vkijs'ku esa gq, [kpZ ds fy;s vihykFkhZ@vukosnd dz-2 chek daiuh ls laidZ fd;k x;k ,oa fu;ekuqlkj Dyse QkeZ mRrjoknh dz-2@vukosnd dz-1@cSad ds ikl tek fd;k x;k ijarq vukosndx.k }kjk mRrjoknh dz-1@ifjokfnuh ds nkos dks bl vk/kkj ij fd ikfylh dh 'krZ dz- 9, A iib ds rgr mRrjoknh dz- 1@ifjokfnuh dks gqbZ chekjh ds fy;s nkok Hkqxrku ds fy;s nks o"kZ dk osfVax ihfj;sM gksus ls orZeku esa nkok Hkqxrku ;ksX; u gksus ls vLohdkj fd;k x;kA vukosndx.k }kjk mRrjoknh dz-1@ifjokfnuh dks ikfylh 'krksZ dh tkudkjh ugha nh xbZ Fkh vkSj u gh ikfylh ds lkFk ikfylh 'krksZ dks fn;k x;k Fkk vr% vukosndx.k }kjk mRrjoknh dz- 1@ifjokfnuh ds nkos dks fujLr dj lsok esa fuEurk dh xbZ gSaA 16- vukosndx.k }kjk vius tokcnkos esa ;g izfrj{kk yh gS fd mRrjoknh dz-1@ifjokfnuh vLirky es fnukad 07-06-2016 dks bZykt gsrq HkrhZ gqbZ Fkh vkSj izFke chek dh ikfylh fnukad 25-03-2015 dks izkjaHk gqbZ FkhA chek ikfylh ds 'krZ dz- 9, A iib ds rgr nks o"kZ dh vof/k lekfIr ds iwoZ genitourinary surgery gksus ls chek nkos dk Hkqxrku gsrq // 9 // vukosnd chek daiuh nkf;Rok/khu ugha gSA vukosndx.k }kjk mRrjoknh dz-1@ifjokfnuh dk nkok fu;ekuqlkj fujLr fd;k gSA 17- tgka rd ikfylh 'krksZ dk laca/k gS ;g fof/k dk lqLFkkfir fl)kar gS fd chek ikfylh dh 'krksZ ls mHk;i{k focaf/kr gSA ftyk Qksje] jkT; vk;ksx rFkk jk"Vªh; vk;kx dks Hkh 'krksZ ls ijs tkdj vkns'k nsus dh vf/kdkfjrk ugha gSA 18- Bharathi Knitting Company vs. DHL Worldwide Express Courier Division of Airfreight Ltd. (1996) 4 Supreme Court Cases 704, esa ekuuh;
loksZPp U;k;ky; }kjk ;g fu/kkZfjr fd;k x;k gS fd%& "6.............it was stated that a person who signs a document containing contractual terms is normally bound by them even though he has not read them, and even though he is ignorant of their precise legal effect. But if the document is not signed, being merely delivered to him, then the question arises : whether the terms of the contract were adequately brought to his notice ? The terms of the contract have elaborately been considered and decided. The details thereof are not necessary for us to pursue. It is seen that when a person signs a document which contains certain contractual terms, as rightly pointed out by Mr. R.F. Nariman, learned Senior Counsel, that normally parties are bound by such contract; it is for the party to establish exception in a suit. When a party to the contract disputes the binding nature of the singed document, it is for him to prove the terms in the contract or circumstances in which he came to sign the documents need to be established."
// 10 // 19- Export Credit Guarantee Corpn. of India Ltd. vs. M/s Garg Sons International, II (2013) CPJ 1 (SC), esa ekuuh; loksZPp U;k;ky; }kjk ;g fu/kkZfjr fd;k x;k gS fd%& "9. The insured cannot claim anything more than what is covered by the insurance policy..... the terms of the contract have to be construed strictly, without altering the nature of the contract as the same may affect the interests of the parties adversely."
20. United India Insurance Company Ltd. vs. M/s Harchand Rai Chandan Lal, 2005 (1) CPR 64 (SC); esa ekuuh; loksZPp U;k;ky; }kjk ;g fu/kkZfjr fd;k x;k gS fd%& "6. The terms of the policy have to be construed as it is and we cannot add or subtract something. Howsoever liberally we may construe the policy but we cannot take liberalism to the extent of substituting the words which are not intended. It is true that in common parlance the term 'burglary' would mean theft but it has to be proceeded with force of violence. If the element of force and violence is not preset then the insured cannot claim compensation against theft from the insurance company. (Para 6).
It is not open to interpret the expression appearing in policy in terms of common law; but it has to give meaning to the expression reproduced the terms of the policy as also the definition of burglary and / or housebreaking as defined in the policy."
// 11 //
21. Narsingh Ispat Ltd. Vs. Oriental Insurance Co. Ltd. and Anr.
2017 (2) CPR 856 (NC), esa ekuuh; jk"Vªh; vk;ksx }kjk ;g fu/kkZfjr fd;k x;k gS fd%& "Insurance Contract is a species of commercial transaction and it must be construed strictly like any other contract to its own terms and by itself. Insurance contract like any other contract is binding on parties and endeavour of Court must always be to construe contract in context of terms and conditions in insurance policy."
22. A.V. Cottex Limited Vs. The Oriental Insurance Company Limited, 2017 (2) CPR 696 (NC), esa ekuuh; jk"Vªh; vk;ksx }kjk ;g fu/kkZfjr fd;k x;k gS fd%& "Insurance policy is a contract between insured and insurer and its terms and conditions are to be considered as such in same spirit in which they are written and agreed upon by parties."
mijksDr lHkh U;k;n`"Vkarksa esa ekuuh; jk"Vªh; vk;ksx }kjk Hkh ;gh vfHkfu/kkZfjr fd;k x;k gS fd ikfylh 'krksZ dk ikyu djus gsrq ikfylh ds lHkh i{kdkj ij ikfylh 'krZ ca/kudkjh gSA 23- bl izdj.k esa vihykFkhZ@vukosnd dz-2 ,oa mRrjoknh dz- 2@vukosnd dz-1 dh vksj ls ikWfylh 'krksZ dks izLrqr fd;k x;k gSA gkykafd mRrjoknh dz-1@ifjokfnuh }kjk ;g vfHkopu fd;k x;k gS fd mRrjoknh dz-1@ifjokfnuh dks uk rkss igys o"kZ vkSj u gh ikfylh fjfuoy ds nwljs o"kZ ikfylh dh 'krsZ iznku dh xbZ gSA nLrkostksa ds voyksdu ls ;g fofnr gksrk gS fd vukosndx.k }kjk lcls igys ifjokfnuh ds ifr dks 25-03-2015 dks ikfylh tkjh dh xbZ FkhA tks ,d o"kZ ds fy;s Fkh iqu% nwljs o"kZ Hkh fnukad 25-03-2016 ls 24-03-2017 rd // 12 // ikfylh tkjh dh xbZ FkhA ifjokfnuh }kjk vius ifjokn i= esa ;g vfHkopu fd;k gS ^^mRrjoknh dz-1@ifjokfnuh ds ifr }kjk foxr nks o"kksZ ls fu;fer :i ls ikfylh dz; dh tk jgh gSA iz'uk/khu ikfylh f}rh; ikfylh gSA** blls Li"V gS fd ifjokfnuh dks ikfylh 'krksZ ds laca/k esa Li"V tkudkjh Fkh vkSj ;fn chek daiuh }kjk ikfylh ds fu;e ,oa 'krksZ dks iznku ugha fd;k x;k Fkk rks igyh ikfylh ds ckn gh mRrjoknh dz-1@ifjokfnuh dk ;g drZO; Fkk fd vukosnd dz-1 ,oa 2 dks lwfpr djrk ;k ikfylh dks fujLr djrk] ijarq mRrjoknh dz- 1@ifjokfnuh }kjk mlds ckn Hkh nwljs o"kZ ikfylh dks dz; fd;k x;kA blls ;gh izekf.kr gksrk gS fd mRrjoknh dz-1@ifjokfnuh dks ikfylh ds fu;e ,oa 'krksZ dh iw.kZ tkudkjh FkhA vkSj mls Lohdkj dj i'pkrorhZ ikfylh dks izkIr fd;k x;k gSA 24- vukosndx.k }kjk izdj.k esa jsiqfM;s'ku ysVj dk mYys[k fd;k gS ftlds vuqlkj %& "With reference to your cashless authorization request for hospitalization of above mentioned patient, we have scrutinized your request with respect to policy terms & conditions. And we regret to inform you that we are unable to sanction the cashless benefit for the said hospitalization due to following reasons:
As per the submitted documents, patient will be admitted on 07/06/2016 with the diagnosis of? Fibroid Uterus? Ovarian mass and to be managed surgically (which is a genitourinary surgery)- As per section 9 A ii b of policy, a waiting period of 2 years is applicable for any genitourinary surgery. As the date of first inception of policy is 25/03/2015 the policy is in second year. Hence the claim is repudiated under the above mentioned section of the policy terms and conditions. Please note that the cashless claim rejection for the said request does not imply denial of treatment and does not in way prevent // 13 // you from seeking necessary medical attention or hospitalization and claiming for reimbursement subject to policy terms & conditions."
bl izdkj bl fjiqfM;s'ku ysVj ds voyksdu ls ;g fofnr gksrk gS fd vukosndx.k }kjk mRrjoknh dz-1@ifjokfnuh ds tks nkos dks fujLr fd;k gS og ikfylh 'krksZ ds vuqlkj mfpr gS A vukosndx.k }kjk lssD'ku&9 ds vuqlkj mRrjoknh dz-1@ifjokfnuh dk nkok fujLr fd;k gSA ;g Exclusion Clause fuEukuqlkj gS%& Section.9. Exclusions A. Waiting Periods "All claims payable will be subject to the waiting periods specified below:
i. General waiting period of 30 days for all claims payable under the Policy except claims arising due to an Accident. ii. A waiting period of 24 months shall apply to the treatment, whether medical of surgical, of the disease/conditions mentioned below. Addionally the said 24 months waiting period shall be applicable to all surgical procedures mentioned under surgeries in the following table, irrespective of the disease/condition for which the surgery is done, except claims payable due to the occurrence of cancer.
a. lllnesses: Internal Congenital disease, non infective arthritis; calculus diseases of gall bladder including cholecystitis and urogenital system e.g. Kidney stone, Urinary Bladder Stone Pancreatitis, Ulcer and erosion of stomach and duodenum; Gastro Esophageal Reflux Disorder(GERD): All forms of Cirrhosis (Pls note: all forms of cirrhosis due to alcohol will be excluded): Perineal Abscesses,Perianal Abscesses: cataract; fissure/fistula in anus, hemorrhoids, pilonidal sinus,: gout and rheumatism; internal tumors, cysts, nodules, polyps including breast lumps (each of any kind unless malignant); osteoarthritis and osteoporosis; polyystic ovarian diseases; Fibroids (fibromyoma) , sinusitis; Rhinitis, Tonsillitis and skin tumorsunless malignant; Benign Hyperplasia of Prostate.
b. Treatments: adenoidectomy, mastoidectomy, tonsillectomy and tympanoplasty); dilatation and curettage (D & C); joint replacement: myomectomy for fibroids; surgery of genito urinary system unless necessitated by malignancy; surgery of hydrocele/ Rectocele; surgery for prolapsed inter vertebral disk, joint // 14 // replacement surgeries surgery of varicose veins and varicose ulcers; Surgery for Nasal septum deviation, nasal concha resection."
mRrjoknh dz-1@ifjokfnuh }kjk pwafd 24 ekg ds Hkhrj mijksDr ltZjh djkbZ Fkh blfy;s viotZu Dykl ds vuqlkj mRrjoknh dz- 1@ifjokfnuh nkok jkf'k izkIr djus dh vf/kdkfj.kh ugha gSA vukosndx.k }kjk mRrjoknh dz-1@ifjokfnuh ds nkos dks fof/kor fujLr fd;k gSA 25- mijksDr foospuk ds ifjizs{; esa ftyk Qksje }kjk ikfjr vkyksP; vkns'k =qfViw.kZ gS o fLFkj j[ks tkus ;ksX; ugha gS vr% vihykFkhZ@vukosnd dz-2 dh vihy Lohdkj dh tkrh gSA ftyk Qksje }kjk ikfjr vkns'k fnukad 23-12-2017 vikLr fd;k tkrk gSA ifj.kker% ifjokn fujLr fd;k tkrk gSA izdj.k dh ifjfLFkfr;ksa dks ns[krs gq, i{kdkj bl vihy dk O;; viuk&viuk ogu djsxkA ¼U;k;ewfrZ vkj-,l-'kekZ½ ¼Mh-ds-iksn~nkj½ ¼ujsUnz xqIrk½ ¼Jherh :fp xks;y½ v/;{k lnL; lnL; lnL;k 24@07@2018 24@07@2018 24@07@2018 24@07@2018