CLINIC ASSIGNMENT

MOOT PROBLEM

RESPONDENT SIDE, PROBLEM 3, ISSUE NO. 3

Submitted by

ANKIT GAUTAM

ID: 219100

Section B
LILA. …CLAIMANT

V.

W INSURANCE …
RESPONDENT

Respondent’s Memorandum
 -Table of Contents-

TABLE OF CONTENTS

Index of Authorities..................................................................................................................4

Statement of Facts.....................................................................................................................5

Questions Presented..................................................................................................................7

Arguments Advanced................................................................................................................8

3.1. The claimant's Claim is barred by Limitation Defense and Commencement of

Limitation Period:................................................................................................................8

3.2. The Defence of delay will not be applicable on the Claimant’s claim.................8

Prayer.......................................................................................................................................10
 -Index of Authorities-

INDEX OF AUTHORITIES

Cases

State Bank of India v. Mula Sahakari Sakhar Karkhana Ltd. (AIR 1996 SC 2446).......................5
State of Punjab v. Bhatinda District Co-operative Milk Producers Union Ltd. (AIR 2007 SC
2077)............................................................................................................................................5
Collector Land Acquisition v. Mst. Katiji (AIR 1987 SC 1353).....................................................6
Ramlal v. Rewa Coalfields Ltd. (AIR 1962 SC 361)......................................................................5

Statutes

The Limitation Act, 1963...........................................................................................................7

 -Statement of Facts-

STATEMENT OF FACTS

Mr. Lila (hereinafter referred to as the “Claimant”) and his wife obtained an insurance policy
from W Insurance Company (hereinafter referred to as the “Company”) with effective
coverage from May 20, 2020, to May 19, 2021. The insurance policy included benefits such
as “Home Care Expenses,” specifically extended to cover COVID-19 treatment expenses
incurred at home, from July 1, 2020, to September 30, 2020. On July 14, 2020, both the
Claimant and his wife were diagnosed with COVID-19 and were advised by a qualified
medical practitioner to undergo home-based hospitalisation, receiving continuous medical
monitoring and nursing care. They incurred medical expenses throughout their treatment
period until their discharge on July 27, 2020.

Following their discharge, the Claimant submitted claims to the Company seeking
reimbursement for the COVID-19 treatment expenses incurred during the home-based
hospitalisation. The Claimant provided requisite documentation and bill submissions to
support their claims, expecting coverage under the “Home Care Expenses” benefit of the
insurance policy. However, despite fulfilling all necessary documentation and submission
procedures, the Company remained unresponsive to the Claimant’s claims for an extended
duration. Subsequently, on August 28, 2022, and January 30, 2023, the Company rejected the
claims without providing any provision for an appeal or review process. Instead, the Claimant
was directed to the grievance redressal cell.

The Claimant, along with his wife, both senior citizens, sought reimbursement for the
COVID-19 treatment expenses under the renewed medical insurance policy. Their positive
diagnosis in July 2020 necessitated treatment at home under medical supervision due to the
unavailability of hospital beds and their compromised health conditions.

However, despite the explicit coverage provided under the “Home Care Expenses” benefit of
the insurance policy, the Company twice rejected the claims, citing absence of
hospitalisation. The Claimant contends that their home-based treatment fell within the ambit
of the policy’s coverage, encompassing diagnostic tests, medications, medical consultations,
nursing services, and essential medical equipment. Moreover, the Claimant alleges that the
Company’s refusal to honor their claims was arbitrary and in contravention of the policy
provisions. Additionally, the Claimant asserts that the Company failed to deliver promised
 -Statement of Facts-

services and mismanaged the claim review process, causing mental distress to the Claimant
and his wife.

In light of these facts, the Respondent asserts that the Claimant’s claims were rightfully
denied based on the policy terms and coverage limitations. The Respondent contends that the
Claimant’s claims do not qualify for reimbursement under the insurance policy, as the
treatment provided did not meet the criteria outlined in the policy for coverage under the
“Home Care Expenses” benefit. Furthermore, the Respondent maintains that the rejection of
the claims was in accordance with the terms and conditions of the insurance policy, and there
was no arbitrary or unfair treatment towards the Claimant. The Respondent will vigorously
defend its position and uphold the integrity of the insurance policy terms during the course of
the legal proceedings
 -Questions Presented-

QUESTIONS PRESENTED

1. IS THE CLAIMANT ENTITLED TO THE EXPENSES INCURRED FOR

TREATMENT OF COVID?

2. IS THE CLAIMANT ENTITLED TO COMPENSATION?

3. IS THE CLAIM HIT BY LIMITATION?

 -Arguments Advanced-

ARGUMENTS ADVANCED

3.1. THE CLAIMANT’S CLAIM IS BARRED BY LIMITATION DEFENSE AND

COMMENCEMENT OF LIMITATION PERIOD:

Under the Indian Limitation Act of 1963, Lila’s claim for reimbursement of her medical
expenditures is blocked by a statutory limitation period. 1 Contractual claims are subject to a
three-year statute of limitations, which begins on the date the cause of action accrues, as per
Section 24 of the Limitation Act. The cause of action in this case began when Lila, upon her
discharge on February 27, 2020, made a claim with W Insurance. 2 Lila’s claim was time-
barred since it was filed after the statutory deadline, and the three-year statute of limitations
began on this day.

This view is consistent with the values maintained by several court rulings that highlight the
need of rigorously adhere to statute of limitations periods. The Supreme Court made clear in
Ramlal v. Rewa Coalfields Ltd.3 that parties who have already allowed the statute of
limitations to run out are not entitled to a second chance under the terms of the Limitation
Act. This emphasises how important it is for parties to vigorously pursue their claims within
the allotted time frames. In a same vein, State of Punjab v. Bhatinda District Co-operative
Milk Producers Union Ltd.4 reiterated how important it is to follow the statute of limitations
in order to avoid unjustified delays and guarantee the prompt resolution of disputes.

Lila’s claim for reimbursement of medical expenditures is categorically prohibited by the

statutory limitation period established under the Indian Limitation Act, 1963, in light of these
legal principles and precedents.

3.2. THE DEFENCE OF DELAY WILL NOT BE APPLICABLE ON THE CLAIMANT’S CLAIM.

As required by Section 5 of the Indian Limitation Act, 1963, Lila has not given a plausible
explanation for why the claim was not filed within the allotted time frame. If sufficient cause

1
The Limitation Act, 1963
2
State Bank of India v. Mula Sahakari Sakhar Karkhana Ltd. (AIR 1996 SC 2446)
3
Ramlal v. Rewa Coalfields Ltd. (AIR 1962 SC 361)
4
State of Punjab v. Bhatinda District Co-operative Milk Producers Union Ltd. (AIR 2007 SC 2077)
 -Arguments Advanced-

is demonstrated, Section 5 permits a delay to be excused; nonetheless, it sets the onus of

proof on the claimant to offer a legitimate and substantial explanation for the delay.
Lila has not provided any convincing justification in this instance for why the claim was not
filed within the allotted time. Lila knew about the medical costs she would spend over the
course of treatment, but she failed to submit the claim within the allotted three years of
statute of limitations. If there is not a compelling reason for the wait, this inaction cannot be
justified.

A number of court rulings support the need that claimants provide evidence of a substantial
reason why they delayed pursuing remedies. According to the Supreme Court’s ruling in
Collector Land Acquisition v. Mst. Katiji, 5 a simple mistake or delay cannot be excused. The
claim will expire if the claimant cannot give a good and substantial explanation for the delay.
Furthermore, the Indian Limitation Act, 1963, Section 5, states that the court may excuse a
claimant’s delay if it is satisfied with the justifications offered. Without a good reason for the
delay, this clause should not be exploited to get around the statute of limitations.

5
Collector Land Acquisition v. Mst. Katiji (AIR 1987 SC 1353)
 -Prayer-

PRAYER

For the foregoing reasons, the Claimant respectfully requests the Court to:

1. DECLARE that the Claimant is not entitled to the expenses incurred for treatment of

COVID.

2. DECLARE that the Claimant is not entitled to compensation on account of legal

expenses, mental agony and harassment suffered by the complainant and his wife.

3. DECLARE that the Claimant’s claims are barred by the Limitation.