ORIENTAL INSURANCE CO LTD Vs. SUBHASH CHANDRA TONDON

JUDGEMENT

(1.) The complainant/respondent obtained a PNB-Oriental Royal Mediclaim Insurance Policy dated 04.11.2011, from the petitioner company. The aforesaid policy was issued to him pursuant to a proposal submitted by him to the insurance company. The term of the policy was one year w.e.f. 04.11.2011. The complainant underwent a prostate surgery on 14.05.2012, incurring expenditure of Rs. 73,600/-. The claim submitted by him however, was rejected by the petitioner company on the ground that surgery of BPH (Benign prostatic Hypertrophy) was not covered for the first two years of the policy. Reliance in this regard was placed on clause 4.1 & 4.1 of the prospectus issued by the insurance company for the mediclaim policy.

(2.) A perusal of the proposal form submitted by the complainant would show that he expressly declared to the insurance company that he had read the prospectus, understood the same and accepted the policy subject to the exclusions and conditions prescribed therein. In view of the aforesaid declaration, there can be no denial that a prospectus had been issued by the insurance company for PNB-Oriental Royal Mediclaim Policy and the said prospectus was duly read and understood by the complainant, before he submitted the proposal form. The complainant has not placed on record the prospectus which he has referred in the declaration signed by him. The insurance company on the other hand, has placed on record, the aforesaid prospectus and clause 4.2 of the aforesaid prospectus reads as under:

(3.) The learned counsel for the complainant maintains that in fact no prospectus was made available to the complainant. We however, cannot accept the said contention in view of the declaration contained in the proposal form wherein the complainant expressly referred to the prospectus and the terms and conditions contained therein were duly accepted by him.