PER SURESH CHANDRA, MEMBER The complainant/respondent took a joint mediclaim policy along with his wife from petitioner/OP Insurance Co. on 19.10.1997 valid up to 18.11.1998. The said policy covered each of the insured for Rs.1 lakh. It is stated that the complainant forgot to renew the said policy which was later renewed on 24.12.1998 for a period of one year with the insurance cover of Rs.2.5 lakh each. The wife of the complainant came to be admitted into Escorts Heart Institute and Research Centre on 21.05.1999. She was treated for the cart and device closure of ASD on 22.05.1999 and was discharged on 23.05.1999. The complainant filed a claim of Rs.1,55,534.50 with the OP Company which was repudiated and hence the complainant lodged a complaint with the District Forum. On appraisal of the pleadings and the evidence adduced, the District Forum observed that the claim of the complainant falls within the exclusion clause 4.3 of the policy in question and hence not tenable. The complaint was accordingly dismissed. The complainant challenged the order of the District Forum before the Delhi State Commission by filing an appeal which was allowed by the impugned order dated 23.11.2006 and the petitioners were directed to pay Rs.1,55,534/- with 9% interest from the date of repudiation of the claim till the date of impugned order and Rs.5,000/- as cost of litigation. This impugned order has been challenged through the present revision petition. 2. We have heard counsel for the petitioner and respondent in person. It is not in dispute that the joint mediclaim policy taken by the complainant expired on 18.11.1998. It is the contention of the petitioner Company that the policy which came to be issued w.e.f. 24.12.1998 for a period of one year from that date with an increased insurance cover of Rs.2.5 lakh each was a new policy and not renewal of the earlier policy with lesser cover which, in any case, had expired on 18.11.1998. In view of this, the fresh policy was subject to the terms of the exclusion clause 4.3 and since the disease for which the complainant’s wife was treated fell within the diseases excluded under this clause, the claim put fourth by the complainant was rightly repudiated by the petitioner Company. We have seen the policy document in question, a copy of which has been placed on record by the petitioner Company. We have also seen the document by which the insured person’s details were submitted by the complainant in respect of his wife for getting policy with higher cover of Rs.2.5 lakh each. Admittedly, it is not mentioned anywhere to indicate that the increased cover is under a renewal policy and by all accounts, the policy in question is a new policy which would obviously be subject to the terms of exclusion clause 4.3 contained in the medical insurance policy document. The said exclusion clause reads thus:- “4.3 During the first year of the operation of insurance cover, the expenses on treatment of diseases such as Cataract, Benign Prostatic Hypertrophy. Hysterectomy for Menorrahagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal Disease, Fistula in anus, Piles, Sinusitis and related disorders are not payable. If these diseases are pre-existing at the time of proposal they will not be covered even during subsequent period of renewal too” 3. It is the contention of the counsel for the petitioner that as per medical opinion, Arterial Septal Disease (ASD) for which the wife of the complainant was treated at the Escorts Hospital is nothing but Congenital Heart Disease (CHD) but the same was not disclosed in the proposal form. In any case, since the ailment was contracted within one year of the policy, it would fall within the exclusion clause 4.3 of the policy reproduced above. We find that the State Commission erred in not taking into consideration this important documentary evidence in favour of the contention of the petitioner Company while admitting the appeal of the complainant and setting aside the order of the District Forum. The impugned order, therefore, cannot be sustained in the face of the aforesaid specific clause of the policy document and the undisputed averments made by the petitioner. Consequently, the revision petition stands allowed and the impugned order is set aside with the parties bearing their own costs. Learned counsel for the petitioner Company has submitted that vide our order dated 16.05.2007, the petitioner Company had deposited the decretal amount under the impugned order with this Commission. In view of today’s order, the Registry is directed to refund the amount so deposited by the petitioner Company along with interest accrued thereon. |
