Kerala

StateCommission

A/09/220

National Insurance Co Ltd. - Complainant(s)

Versus

JIji George - Opp.Party(s)

Rajan P Kaliyath

20 Sep 2010

ORDER

First Appeal No. A/09/220

(Arisen out of Order Dated 21/10/2008 in Case No. CC 21/08 of District Idukki)

1. National Insurance Co Ltd.

Kerala

...........Appellant(s)

Versus

1. JIji George

Kerala

...........Respondent(s)

BEFORE:
	Sri.M.V.VISWANATHAN PRESIDING MEMBER

PRESENT:

ORDER

KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION

VAZHUTHACAUD THIRUVANANTHAPURAM

APPEAL NO.220/09

JUDGMENT DATED 20/09/2010

PRESENT

SMT.VALSALA SARANGADHARAN -- MEMBER

SRI.M.V.VISWANATHAN -- JUDICIAL MEMBER

SRI.M.K.ABDULLA SONA -- MEMBER

The Branch Manager,

National Insurance Company Ltd.

Thodupuzha Branch,

Pulimoottil Shopping Arcade -- APPELLANT

Thodupuzha 685 584.

(By Adv.Rajan P.Kaliyath)

Vs.

Jiji George,

Karinthel House, -- RESPONDENT

Narakakkannam Post,

Idukki, Idukki District.

(By Adv.Asokkumar)

JUDGMENT

SRI.M.V.VISWANATHAN,JUDICIAL MEMBER

Appellant was the opposite party and respondent was the complainant in CC.21/08 on the file of CDRF, Idukki. The complaint therein was filed alleging deficiency in service on the part of the opposite party/National Insurance Company Ltd. in repudiating the Insurance claim based on the mediclaim Policy No. 500801/48/04/8500000586 for the period from 1.11.05 to 31.10.06. The complainant claimed the insurance claim amount with interest at the rate of 18% per annum and also for compensation of Rs.10,000/- with cost of Rs.3000/-.

2. The opposite party entered appearance and filed written version denying the alleged deficiency in service on their part. The opposite party justified the action in repudiating the insurance claim. It was contended that the insured K.V.George was admitted in hospital on 3/9/05 and continued the treatment till his death on 31.1.06; that the insured had availed the insurance claim of Rs.50,000/- during the policy period from 1.11.04 to 31.10.05; that the liability under mediclaim is based on the date of admission in the hospital and not on the basis of date of discharge from the hospital. Thus, the opposite party prayed for dismissal of the complaint.

3. Before the Forum below a witness on the side of the complainant was examined as PW1. P1 and P2 documents were also marked on the side of the complainant. The Manager of the opposite Party National Insurance Company Ltd., Thodupuzha Branch was examined as DW1 and R1 to R8 documents were marked on the side of the opposite party. On an appreciation of the evidence on record, the Forum below passed the impugned order dated 21.10.08 allowing the complaint in OP.21/08 directing the opposite party to pay the insurance claim of the complainant based on the mediclaim Policy No. 500801/48/04/8500000586 for the period from 1.11.05 to 31.10.06 with cost of Rs.2000/-. Hence the present appeal.

4. We heard the learned counsel for the appellant/opposite party and the respondent/complainant. The counsel for the appellant submitted his arguments based on the grounds urged in the memorandum of the present appeal. He much relied on Clause 3 of the conditions of the policy with respect to the term “anyone illness” and canvassed for the position that the insured had exhausted the insured amount of Rs.50,000/- for the aforesaid illness during the insurance period from 1.11.04 to 31.10.05 and that the claim in CC.21/08 is also based on the very same treatment for which the insured was admitted on 3.9.05. Thus, the appellant/opposite party prayed for setting aside the impugned order passed by the Forum below. On the other hand, the learned counsel for the respondent/complainant supported the impugned order passed by the Forum below. He canvassed for the position that no insurance claim was granted by the opposite party/Insurance Company for the insurance period from 1.11.05 to 31.10.06. It is also submitted that the insured was admitted in the hospital on 3.9.05 and continued his treatment till his death on 31.1.06 and that the opposite party/Insurance Company has not allowed any claim for the aforesaid treatment from 3.9.05 to 31.1.06. Thus, the respondent prayed for dismissal of the present appeal.

5. The respondent/complainant is the wife of K.V. George, the holder of the mediclaim insurance policy. Admittedly, the insured K.V.George had the mediclaim insurance coverage by the virtue of the insurance policy No. 500801/48/04/8500000586 for the period from 1.11.04 to 31.10.05. The insured K.V.George was having the aforesaid mediclaim policy for the subsequent period from 1.11.05 to 31.10.06 vide mediclaim policy No. 500801/48/04/8500000586. There can be no dispute about the fact that the insured had exhausted the insurance claim of Rs.50,000/- with respect to the mediclaim policy for the period from 1.11.04 to 31.10.05. The insured amount was Rs.50,000/-. Thus, the insured amount of Rs.50,000/- was exhausted by the claim No.CCN 52389 for Rs.7703/-, claim No. CCN 54143 settled for Rs.4831/- and claim No.CCN 67031 settled for Rs. 37466/- = 50,000/-. It is to be noted that the aforesaid insurance claims were settled for the treatment prior to 3.9.05. There is also no dispute with respect to the aforesaid 3 claims settled during the relevant period ie; during 1.11.04 to 31.10.05.

6. The insured K.V.George got the mediclaim policy renewed for the subsequent year namely from 1.11.05 to 31.10.06. It is an admitted fact that the opposite party/Insurance Company had not sanctioned any claim with respect to the insurance policy for the period from 1.11.05 to 31.10.06. Ext.R2 is the policy for the said period from 1.11.05 to 31.10.06. The previous year’s policy is R1 policy. The aforesaid 3 claims were settled with respect to R1 mediclaim policy. Therefore, it can very safely be concluded that the appellant/opposite party Insurance Company was legally bound to honour the claim based on R2 mediclaim policy for the period from 1.11.05 to 31.10.06.

7. The definite case of the respondent/complainant was that the present claim has been preferred by the respondent/complainant being the wife of the insured who died on 31.1.06. It is to be noted that the respondent/complainant being the legal heir and wife of the insured submitted the insurance claim based on R2 mediclaim policy. The aforesaid claim was repudiated by the opposite party/insurance company based on the settlement of the claim with respect to R1 policy. It is to be noted that we are not concerned with the claims settled by the Insurance Company with respect to R1 mediclaim policy. It is also to be noted that the aforesaid 3 claims were settled on the strength of R1 policy during the life time of the insured.

8. The insured K.V.George was admitted in Medical College Hospital, Kottayam on 3.9.05 and continued his treatment up to 9.9.05. Thereafter, the insured K.V.George was re-admitted in Medical College Hospital, Kottayam on 24.9.05 and continued the treatment till his death on 31.1.06. The aforesaid fact can be seen from R4 medical certificate issued by Dr.K.P.Jayakumar, Head and Director of Nephrology, Medical College, Kottayam. R5 is dated 18.3.06. R5 medical certificate would also make it clear that the insured Mr.George was admitted in Medical College Hospital on 3.9.05 and discharged on 9.9.05 and that thereafter the patient George was re-admitted on 24.9.05 and treatment continued till his death on 31.1.06. R5 Medical Certificate would also make it clear that Nephrectomy operation was done on the patient on 31.10.05. Very important aspect to be noted at this juncture is the admitted fact that no Insurance claim was sanctioned by the appellant/opposite party Insurance Company for the treatment of the insured with respect to his treatment from 3.9.05 onwards. The mere fact that the insured had exhausted the insurance claim of Rs.50,000/- by the prior 3 Insurance claims cannot be taken as a ground to hold that the insured is not entitled to the claim for the subsequent period ranging from 1.11.05 till his death on 31.1.06. The appellant/opposite party Insurance Company is legally bound to honour the insurance claim with respect to the R2 mediclaim policy for the period from 1.11.05 to 31.10.06. So, the present claim is based on R2 policy for the period from 1.11.05 to 31.10.06. Unfortunately, the insured died on 31.1.06. If that be so, the claim made by the respondent/complainant for the period from 1.11.05 to 31.1.06 is to be honoured by appellant/opposite party Insurance Company.

9. The Forum below has only directed the opposite party/Insurance Company to pay the insurance claim to the complainant being the wife and legal heir of the insured K.V.George for the prevailing mediclaim insurance policy from 1.11.05 to 31.10.06 (R2 policy) along with interest at the rate of 12% per annum from the date of the complaint with cost of Rs.2000/-. The opposite party/Insurance company has also been made liable to pay future interest at the rate of 12% per annum in the event of default to pay the decree amount. It is pertinent to note at this juncture that the Forum below has only awarded the insurance claim based on R2 policy for the period from 1.11.05 to 31.10.06. The case of the appellant/opposite party that the Insurance claim is based on the date of admission and not based on the date of discharge cannot be accepted as such. Ext.R2 policy and the policy conditions would not give any indication that date of admission is the crucial aspect for allowing the insurance claim. It is to be noted that the mediclaim policy was taken to get the treatment expenses reimbursed. The R2 policy was taken to cover the risk for the period from 1.11.05 to 31.10.06. The insured K.V.George had undergone treatment for illness during the said period ranging from 1.11.05 up to 31.1.06. The respondent/complainant being the legal heir and wife of the deceased/insured is entitled to get the treatment expenses re-imbursed on the strength of R2 policy, which was valid and effective during the aforesaid relevant period. So, the Forum below is justified in allowing the complaint in CC.21/08.

10. The learned counsel for the appellant/opposite party Insurance Company much relied on Clause 3 regarding the term “anyone illness”. It is as follows.

“Anyone illness will be deemed to mean continuous period of illness and it includes relapse within 45 days from the date of last consultation with the Hospital/Nursing Home where treatment has been taken. Occurrence of same illness after a lapse of 45 days as stated above will be considered as fresh illness for the purpose of this policy”.

11. It is to be noted that as far as the insurance claim based on R2 mediclaim policy is concerned, the aforesaid Clause 3 “anyone illness” has no application at all. There is no case for the appellant/opposite party Insurance Company that for the treatment from 3.9.05 up to 31.1.06 any previous claim was made by the respondent/complaint or the insured K.V.George. The present claim is made for the first time by the respondent/complainant being the nominee/legal heir/wife of the insured. It may be correct to say that the insured had availed the benefit of the insurance coverage for a total of Rs.50,000/- based on R1 mediclaim policy. It is also correct to say that R1 policy was effective up to 31.10.05. The treatment, which commenced on 3.9.05, continued till the death of the insured on 31.1.06. R1 mediclaim policy was renewed with effect from 1.11.05 up to 31.10.06. For the aforesaid mediclaim policy (R2) the Insurance Company is liable to indemnify the insured or his legal heir by re-imbursing the treatment expenses for the period from 1.11.05 up to the death of the insured on 31.1.06. The mere fact that the treatment for the said illness commenced on 3.9.05 during the period of R1 mediclaim insurance policy cannot be taken as a ground to hold that the insured or his legal heir is not entitled to get the insurance coverage for the subsequent period ranging from 1.11.05 till the death of the insured on 31.1.06. Thus, in all respects, the appellant/opposite party Insurance Company was legally bound to honour the insurance claim with respect to the treatment expenses for the period from 1.11.05 up to 31.1.06. Even if there occurred any doubt or ambiguity regarding the entitlement of the insured or his legal heir to get the benefit under the policy, the terms of the policy can only be interpreted or construed in favour of the insured or his legal heir. It has been held by the Hon. Supreme Court as early as in the year 1966 in the case of General Assurance Society Vs. Chandmull Jain and Anr. Reported in AIR 1966 Supreme Court 1644 that in case of ambiguity or doubt about the contract of Insurance, the terms of the contract of insurance is to be interpreted or construed in favour of the insured and against the Insurance Company. Relying on the aforesaid dictum laid down by the Supreme Court in the aforesaid case (supra) it can very safely be held that the Forum below has rightly directed the opposite party/Insurance Company to honour the medicalim based on R2 policy for the treatment expenses which incurred for the period from 1.11.05 to 31.10.06. We do not find any reason or ground to interfere with the impugned order passed by the Forum below. Thus, the present appeal deserves dismissal.

In the result, appeal is dismissed. The impugned order passed by the Forum below is confirmed. As far as the present appeal is concerned, there will be no order as to costs.