Delhi

New Delhi

CC/671/2011

Milanka Chaudhury - Complainant(s)

Versus

M/S. Iffco Tokio General Insurance Company Ltd. - Opp.Party(s)

27 May 2015

ORDER

CONSUMER DISPUTES REDRESSAL FORUM-VI

(DISTT. NEW DELHI), ‘M’ BLOCK, 1^STFLOOR,

VIKAS BHAWAN, I.P.ESTATE,

NEW DELHI-110002.

 

Case No.CC/671/11                                                                                                                                                                                Dated:

In the matter of:

Mr. Milanka Chaudhury,

S/o Mr. Dhirendra Chaudhury,

R/o C-105, ATS Greens I,

Sector-50, Noida-201301

                 ……..COMPLAINANT

       

VERSUS

1. IFFCO-TOKIO General Insurance Co. Ltd.,

        4^th floor, 416-421 Narain Manzil,

        23, Barakhamba Road, Connaught Place,

        New Delhi-110001

        Regd. Office at:

        IFFCO Sadan, C-1, District Centre,

        Saket, New Delhi-110017    

 

2. Rakhsa TPA Pvt. Ltd.,

C/o Escorts Corporate Centre,

15/5 Mathura Road, Faridabad,

Haryana-121003

………. OPPOSITE PARTIES

 

ORDER

President:  C.K. Chaturvedi

The complaint of deficiency relates to denial of medical expenses for the treatment of the son of complainant, by OP replying on exclusion clause in the policy though there policy had been in the 5^th  year, year after year since 22.05.06 to 21.05.07, 22.05.08 to 21.05.09, 03.06.08 to 02.06.09, 13.11.09 to 12.11.10 and 22.11.10 to 21.11.11. During coverage of 1^st policy, his son was born in 2006, and was covered in next policy till 21.05.08. During continuance of this policy, the sons aged 11 months suffer high grade fever, loose motion & febrile seizure and was discharged from Noida Hospital on 23.10.07. The OP allowed cashless facility. The boy again become sick and on 27.02.10, was taken to Apollo Hospital for after a long seizure. After investigation, he was diagnosed as “Idiopathic General Epilepsy”. The complainant spent Rs.61,191/- on treatment, and OP first authorized Rs.25,000/- only  but later on reversed the approval. The claim of reimbursement was later on repudiated on the ground that each policy was a new policy and the exclusion clause applied for any treatment in first 2-3 years. Therefore this complaint of deficiency.

 The OP in its reply has stated that there was a non-disclosure of pre-existing disease for which he was treated at 11 months of age, while taking the policy ending 2010. This is alleged as mala fide and deliberate.

We have considered the contention of OP in the light of relevant law and settled position in cases. The child was born in 2006, he was included in the next policy till 2007, and thereafter policy continued, and during continual of policy, he suffered another severe attack which was first time diagnosed in 2010, as epilepsy. The complainant has rightly contended that, if this had happened in sickness first time of age of 11 months, the OP would have paid. The Hon’ble Supreme Court in the case of Biman Krishna Bose vs. United India Insurance CO. ltd. & Anr. V (2001) SLT 556= (2001) 6 SCC 477 and Delhi High Court in the case of Tavlinder Choudhary vs. Union of India & Anr. for 001, 113(2004) DLT 100, have considered the aspect of renewal of policy and held that late renewal of policy does not mean a new policy. The Hon’ble Delhi High Court observed as under:

“4. Learned counsel for the petitioner strongly relied upon judgment of the Supreme Court in Barman Krishna Bose v. United India Insurance Co. Ltd. and Anr., . A reading of the said judgment shows that a number of aspects raised in the present matter are, in fact, no more rest integral in view of the said judgment of the Supreme Court. This judgment has also been considered by a learned Single Judge of this Court in Ashok Kumar Dhingra and Ors. v. The Oriental Insurance Company Limited and Ors., . The issue of maintainability of writ petition was discussed in Ashok Kumar Dhingra's case (supra) and it was noticed that in Biman Krishna Bose's case (supra), the exercise of jurisdiction by the High Court under Article 226 of the Constitution of India in a similar matter was, in fact, not disapproved and the Supreme Court went on to grant relief. I am inclined to take the same view and, thus, the present petition ought not to be thrown out merely on the ground of maintainability.

5. The Supreme Court in Biman Krishna Bose's case (supra) was of the view that where renewal of the policy is denied on extraneous considerations which are arbitrary, an insurer cannot be denied even the retrospective benefit of the same, who would have b en insured for treatment of the disease during the relevant period of time. It was felt that this would give a handle to the insurance companies to refuse the renewal of policies and would have disastrous effect. The Supreme Court was, thus, of the considered view that once it was found that the act of the insurance company was arbitrary in refusing to renew the policy, the policy is required to be renewed with effect from the date when it fell due for its renewal. It may be noticed that in the said c se, the renewal had been denied on the ground that the petitioner therein had litigated in various courts with the insurance company about certain claims. This was found to be arbitrary since the petitioner had admittedly succeeded in the claims.”

 

The OP has considered the 4^th policy, taken by gap of 5 months from 3^rd policy as new policy. This is wrong approach only with object of denying just claim. Once, OP in issuing policy and claim is not in respect of some treatment during break up period, it is wrong to deny the policy and call it a new policy.

   We hold the OP guilty of deficiency and direct OP to pay Rs.61,191/- with interest @ 9% from 90^th day of claim till payment.

File be consigned to record room.

Copy of the order be sent to the parties free of cost.

 

        Pronounced in open Court on 27.05.2015.

 

 

(C.K.CHATURVEDI)

PRESIDENT

 

 

(S.R. CHAUDHARY)         (RITU GARODIA)

MEMBER                          MEMBER