Insured cannot file an appeal for claim rejected by Insurer after the stipulated time period. In the instant case the complainant filed the appeal after 2 years. Appeal rejected by Insurance Ombudsman.
Ahmedabad Ombudsman Centre
Case No. 11.002.0001
Mr. Ashok B. Shah
Vs.
The New India Assurance Company Ltd.
Award Dated 04.10.2004
Complainant’s son was hospitalised for back – ache problem. It was the Respondent’ s argument that they repudiated the claim on 23.11.2001 under Clause 4.1 and the representation against repudiation was made by the Complainant only on 1.7.2003 and hence, the claim got time barred under Policy Condition 5.11.
From the Documents it is observed that the Complainant made his representation against repudiation of claim after 18 months, i.e. on 1.7.03, and Respondent gave a formal reply to it on 12.2.2004. The Complaint was filed with this office on 25.02.2004.
During hearing also the Complainant could not explain the delay and no satisfactory pleading was put forward. Except a ploy, nothing could be found serious on the part of the Complainant. Hon’ble Supreme court judgement in National Insurance Company Vs. Ganesh Nayak & Anr. (AIR 1997 SC 2047) also referred to decide the case wherein the Hon’ble Supreme Court held that “if the Policy of insurance provides that if a claim is made and rejected and no action is commenced within the time stated in the Policy the benefits flowing from the Policy shall stand extinguished and any subsequent action would be time barred, such a Clause will fall outside the scope of Sec. 28 of the Contract Actâ€.
Complaint dismissed without any relief to the complainant.
