The complainant had taken Oriental bank Mediclaim Policy for the period from 06/09/2016 to 05/09/2017 with a sum insured of Rs 200000/ for himself and his family. The spouse of the complainant had a problem of acute cholecystitis and Cholelithiasis, where laparoscopic cholecystectomy was conducted on 28.02.2017. The complainant had lodged a claim with the company for reimbursement but the same was rejected by the company . The complainant stated that the company had rejected the claim of his spouse because of a break in insurance due to the fault of the Bank . He had regularly taken the policy from the company for the last five years.
The premium of the policy of Rs.3399/- was debited from his account on 23.08.2016 instead of 26/07/2016 hence the policy period should be effective from 23.08.2016 instead of 05.09.2016; which is less than one month and very much within grace period. The company stated that the policy, on which the claim was reported was renewed after a gap of 41 days and the previous policy was also renewed after a gap of 16 days, hence the current insurance policy was treated as a fresh policy. As per terms and conditions of the policy there is a waiting period of 2 years for the treatment of cholelithiasis (stone) disease and if continuity of the policy was not maintained then subsequent cover was to be treated as fresh policy, hence the claim of the complainant was rejected by the company under clause 4.2 of the policy, which states that the expenses on treatment of calculus disease for the period of two years is not payable if contracted and/or manifested during the currency of the policy. The insured did not appear for a personal hearing. From the records, it was noticed that the premium as claimed by the complainant was debited within one month, confirming the break in insurance is within 30 days.
Hence the Insurer should settle the claim on merit as agreed by them after condoning the delay, which is less than 30 days. Once this is considered, the treatment of cholelithiasis would not fall within two years. Hence, an award was passed with the direction to the insurance company to provide all the continuity benefits of renewal under the policy to the complainant after condoning the delay.
