A Rajesh, President.
The case of the complainant is as follows:
The complainant availed himself of a ‘Health Shield Insurance’ policy from the opposite party in 2005 covering himself and his parents. Thereafter the policy is renewed up to date. On 03-09-2008 that is one month prior to its expiry the complainant’s father issued a cheque in favour of the opposite party to renew the policy. The cheque was returned after much delay by the 1st opposite party stating that branch name of the bank is not seen in the cheque. The complainant rectified the defect forthwith and the cheque was enchased by the opposite party. On 17-08-2009 the mother of the complainant was hospitalized for uterus related disorders. The claim application for insurance was repudiated by the opposite party stating that the policy is treated as a fresh policy and the claim comes under the first year exclusions. Thereafter the father of the complainant underwent treatment for heart disease on 03-08-2009, 21-08-2009,09-09-09 and 26-01-2010. All the claims for insurance were rejected by the opposite party stating that the disease was pre-existing. The complainant is entitled to get the insurance claims of his parents together with costs of the proceedings. Hence this complaint.
2. Version of the opposite parties.
The complainant had availed health shield Insurance Policy from the opposite parties for the period from 28-1-2008 to 27-10-2009 covering him and his family. Mother of the complainant was treated for forbriod uterus requiring hysterectomy which was excluded by the terms and conditions of the pay as first year exclusion. The father of the complainant was treated for ischemic heart disease along with pre-existing diabetes mellitus since one year which is excluded by clause 1 (b) of the terms and conditions of the policy. There is no deficiency in service on the part of the opposite parties. Opposite parties are not liable to pay any amount to the complainant.
3. The witness for the complainant was examined as PW1, Exts. A1 to A8 were marked on the side of the complainant. No oral evidence was adduced by the opposite parties. Exts. B1 to B3 were marked on the side of the opposite parties. Heard the counsel for the parties.
4. The points that arose for consideration are.
i. Whether the complainant is entitled to get insurance claims from the opposite parties?
ii. Costs of the proceedings.
5. Point No. i. At the instance of the complainant vide order in I.A. 668/2010 dated 15/12/2010 the opposite parties produced the following insurance policy schedules.
Sl.No. | Period of coverage | Policy No. |
i | 22-09-2005 to 21-09-2006 | HS 00031157000100 |
ii | 22-09-2006 to 21-09-2007 | HS 00031157000101 |
iii | 22-09-2007 to 21-09-2008 | HS 00031157000102 |
6. The opposite parties in their version categorically stated that the impugned policy is valid from 28-10-2008 to 27-10-2009. It is pertinent to note that as per Ext. A2 letter dated 25-09-2009 the opposite parties intimated the complainant that the policy in question is a renewal of the earlier policy. The hon’ble Supreme Court held in Biman Krishna Bose V. United India Insurance Co. Ltd. and another (2001) 6 SCC 477 that the renewal of an insurance policy means repetition of the original policy. When renewed the policy is extend in identical terms from a different date of its expiration comes into force.
7. In view of the above we are of the firm opinion that there is no break in the policy and the complainant and his parents have been holding insurance policy since 22-09-2005. So the repudiation of the claims of the parents of the complainant by the opposite parties vide Exts. A4 to A7 is unsustainable in law. In short the opposite parties are liable to pay the insurance claim of the complainant. The complainant has not produced the details of quantum of expenses incurred by him for the treatment of his parents.
8. The very fact that the complainant has not claimed compensation that goes to confirm the bonafides of the claim which is not worthy as to the ingenuity of this case. A cost of Rs. 2,000/- is awarded.
9. In the result, we allow the complaint and direct that
i. the opposite parties shall jointly and severally pay the insurance claim of the complainant on his production of the necessary documents substantiating his claim before the opposite party.
ii. The opposite parties shall jointly and severally pay to the complainant Rs. 2,000/- towards costs of the proceedings.
The above said order shall be complied with within a period of one month from the date of receipt of a copy of this order failing which the above amount shall carry interest @ 12% p.a. till realization.
Pronounced in the open Forum on this the 27th day of July 2011.
