PER SHRI. S.S. PATIL - HON’BLE MEMBER :
1)This is complaint regarding the deficiency in service on the part of Opposite Party as Opposite Party No.2 has repudiated the mediclaim of the Complainant without any valid ground.
2) The facts of the complaint as mentioned by the Complainant are that the Complainant alongwith his wife and son had obtained Individual Mediclaim Policy from New India Assurance Co. Ltd., in the year 1997. It was renewed from time to time. The last Policy No.11200/48/03/09450 was valid form 01/11/03 to 31/10/04. The policy included the Complainant and his wife also. So far as his wife was concerned, the exclusion was none from the date of the inception of the policy. Initially the sum insured was of Rs.2 Lacs. Subsequently it was increased to Rs.3,15,000/-. The insured was having cumulative bonus for years together.
3) The Complainant has further stated that Opposite Party No.2 induced the Complainant to renew the existing policy with higher amount with National Insurance Co. Ltd. i.e. Opposite Party No.1. (The Complainant has not mentioned as to when the Opposite Party No.2 induced the Complainant). It is the contention of the Complainant that the renewed policy was issued by Opposite Parties covering pre-existing diseases under floater risk. The Complainant has stated that the policy was issued by Opposite Party No.1 to the members of Winner Insurance Benefits Ltd., i.e. Opposite Party No.2. The policy was a renewal policy of the earlier Policy issued by New India Assurance Company. Opposite Parties had given one page certificate without terms & conditions. The Complainant has stated that the word, renewal connotes that it is a continuation of earlier polices.
4) It is further contended by the Complainant that for the purpose of renewal of the policy, Opposite Party No.2 obtained proposal form from the Complainant. In the said proposal form, as the wife of the Complainant was not having any ailment known to her, she had answered to various questions in the form as ‘No’.
5) Thereafter they proposed for Overseas Mediclaim Insurance. The said mediclaim insurance was issued under No.2004/2505/01/48/04/05. Thereafter the Complainant & his wife (insured) came back to India and asked further extension of 180 days in their Domestic Mediclaim Policy i.e. Policy No.8500618 from 01/11/04 to 31/10/05. In this connection the Complainant has not mentioned as to when he came back from U.S.A. There was no claim under Overseas Mediclaim Policy. The extension under Domestic Mediclaim policy was granted for 6 months. From 01/11/05 to 26/04/06. The Complainant states that the endorsement ought to have been from 01/10/05 onwards. The Complainant sated that this was a typographical mistake. The policy was printed by Opposite Party on 07/10/05. It is stated by the Complainant that the extension was from 01/10/05 and not from 01/11/05. As per the Complainant, the correct policy period was from 01/11/04 to 31/10/05. Endorsement wording gives correct extension of policy period i.e. from 01/11/05 to 29/04/06 and the endorsement expired on 29/04/06.
6) It is the contention of the Complainant that the original domestic mediclaim policy mentioned the endorsement as from 25/10/05 and expiry date was also 25/10/05. This is not only incorrect but impossible, whereas, the correct policy period as per copy was from 01/11/04 to 31/10/05. The endorsement wording gives correct extension of policy period from 01/11/05 to 29/04/06.
7) The Complainant has further stated that, his wife was hospitalized in November, 2005, in Breach Candy Hospital for treatment of her right knee replacement. The hospitalization was within the period of extension of the policy. The Complainant had requested for cashless settlement. Accordingly cashless facility was granted on 08/11/05 as part payment of Rs.2,50,000/-. Thereafter the Complainant applied for pre and post expenses which were reimbursed to the Complainant. Thereafter well before the period of expiry under extension a cheque of Rs.21,307/- for premium was given before 29/04/06 i.e. before expiry of the extension period of the policy. The Opposite Parties then renewed the policy i.e. from 30/04/06 to 29/04/07.
8) The Insured was again treated for left knee. At this time it was informed that the cashless contract was suspended with the Breach Candy Hospital. The Complainant was asked to file the medical insurance claim. Accordingly the Complainant submitted his claim but the Opposite Party No.2 repudiated the claim of the Complainant vide its letter dtd.02/11/06 giving various reasons. The Complainant has submitted that his wife is covered by the mediclaim policy since, 1997 and her knee problem cropped up in the year 2005 only. Thus, this disease of knee joint was not a pre-existing disease. There was no suppression of material facts. Even the policy has covered by pre-existing disease of the insured as far as his wife is concerned. Earlier policy was renewed with enhanced amount. So the repudiation of the claim is on wrong ground which amounts to deficiency in service.
9) The Opposite Party No.2 has also taken a stand that there was a gap of 6 months from 31/10/05 to 30/04/06, but the Complainant has stated that there was no such gap and the policy was in continuity. Therefore the Opposite Parties have repudiated the claim on absolutely wrong grounds.
10) Further it was the contention of Opposite Party No.2 in the repudiation letter that there were anomalies in endorsement of the policy and further they sought clarification from Opposite Party No.1. However, same was not received. In this regard, the Complainant says that this was their internal problem between Opposite Party No.1 & Opposite Party No.2. Thus, rejecting the claim on the above said false grounds amounts to deficiency in service on the part of Opposite Parties and it also amount to unfair trade practice adopted by the Opposite Parties.
11) Therefore, it is finally prayed by the Complainant that the Opposite Parties be directed to pay the amount of Rs.2,46,991/- with interest, compensation and cost of the complaint.
12) The Complainant has attached the xerox copies of the following documents in support of his complaint –
Policy Schedule – 2003 – 2004 (01/11/03 to 31/10/04 – issued by New India Assurance Co. Ltd., Policy valid from 01/11/04 to 31/10/05 issued to members of Winner Insurance Benefits Ltd. issued by National Insurance Co. Ltd., Forms in the name of Complainant and his wife – with Heading for the members Beneficiary of Winner Insurance Benefits Ltd. – dtd.– blank – No Signature, A blurred policy by National Insurance Company – valid from 26/03/05 to 31/09/05 by National Insurance Co. Ltd.
Policy No.618 – Group Medical – issued on 26/10/04 – from 25/10/05 to 25/10/05 with endorsement extension from 01/11/05 to 29/04/06.
Letter from Heritage Health Services, dtd.08/11/05, Renewal of Policy valid from 30/04/06 to 29/04/07, Doctor’s Certificate dtd.16/10/05, Discharge Card form Breach Candy Hospital, Receipt for renewal of Policy (date 10/04/06 Discharge Card by Breach Candy Hospital dtd.28/08/06), Letter of Repudiation dtd.02/11/06, Complainant’s letter dtd.06/11/06 and 21/07/07.
13) The complaint was admitted and notices were served on Opposite Parties. Opposite Parties appeared before this Forum through their Ld.Advocates and filed their written statement, Opposite Party No.1 has denied in the written statement that the Complainant is its consumer and no cause of action has arisen between the Complainant and Opposite Party No.1. It further stated that the Family Floater Policy bearing No.250501/46/04/8500618 for the period 01/11/04 to 31/10/05 was issued to beneficiary of Winner Beneficiary Trust (Opposite Party No.2). This policy was issued at 1st time in this year and no continuity was granted for risk of New India Assurance Co. Ltd.
14) The Opposite Party No.1 has stated that the Complainant has also taken overseas mediclaim policy for a period 26/03/05 to 21/09/05 from Opposite Party No.1. Thereafter, the Complainant took family floater concept with pre-existing without maternity benefit policy from Opposite Party No.2 for a period 30/04/06 to 29/04/07.
It is further stated by the Opposite Party No.1 that policy/renewed protection No.250501/46/04/8500168 for the period 30/04/06 to 29/04/07 has not been issued by Opposite Party No.1. Hence, the Complainant is not insured with the Opposite Party No.1 and also Complainant is not a consumer of Opposite Party No.1.
15) The Opposite Party No.1 has denied that the policy was a renewal of earlier policy issued by New India Assurance Company. The policy issued by Opposite Party No.1 does not grant continuity of risk of New India Assurance Individual Medical Policy. It is further clarified that the policy issued by New India Assurance Co. and family floater policy issued by Opposite Party No.1 are different policies having different terms and conditions. The Complainant was aware at the time of the inception of mediclaim family floater policy that he is not entitled for the continuity of the risk of previous individual policy issued by New India Assurance Co.
16) Opposite Party No.1 has further stated that, the Complainant’s wife suppressed the material fact and failed to disclose that she is suffering form knee joint at the time of submitting the proposal form. Knee operation is normally done after 3 to 4 years. The Complainant was aware that she was suffering from knee problem at the time of submitting the proposal form.
17) The Opposite Party No.1 has further stated that the Heritage Health Services Pvt. Ltd., inadvertently paid the medical expenses for right knee replacement to the Complainant. It is further stated that neither the Complainant paid Rs.21,307/- as a premium for renewal of policy nor Opposite Party No.1 received any amount and acknowledged any receipt No.4128, dtd.10/04/06. The Opposite Party No.1 has denied that it renewed the policy for period 30/04/06 to 29/04/07 and finally stated that the Complainant is not entitled to any relief.
18) The Opposite Party No.2 also filed its written statement wherein it specifically denied having induced the Complainant to take the policy with various facilities and benefits. It is also denied that the policy covered pre-existing disease under the floater risk. The Opposite Party No.2 has also denied that the letter of extension was given much earlier of 07/10/05 and it is also denied that the hospitalization was within the period of extension of the policy.
19) Opposite Party No.2 has specifically stated that there was a pre-existing disease. It is also denied that there is a deficiency in service & unfair trade practice adopted by the Opposite Parties while repudiating the claim of the Complainant. Finally it is requested to dismiss the complaint with cost.
20) The Complainant thereafter filed the rejoinder and a written argument in which he has reiterated the facts and points mentioned in his complaint. The Opposite Parties also filed their written argument wherein they reiterated the facts mentioned in their written statements.
21) We heard the Ld.Advocates for both the parties and our findings are as follows-
Originally the Complainant and his wife were the insured of New India Assurance Company Ltd. till 31/10/04. The Complainant has stated that the Opposite Party No.2 induced him to renew policy from Opposite Party No.1. But there is nothing on record to show that the Opposite Parties had induced the Complainant to renew the policy obtained by the Complainant from New India Assurance Co. Ltd.
22) Policy No.250501/46/04/8500618 was issued by Opposite Parties. This policy was valid from 01/11/04 to 31/10/05. Covering pre-existing diseases. This policy was issued by Opposite Party No.1 to the members of Opposite Party No.2 i.e. the Complainant & his wife were the beneficiaries of Opposite Party No.2.
23) It is also the contention of the Complainant that the said policy 250501/46/04/8500618 was the renewal of mediclaim policy of New India Assurance Co. Ltd., but Opposite Parties have denied this contention and specifically stated that it was a fresh policy. Careful scrutiny of this policy shows that it is the renewal of earlier policy issued by New India Assurance Co. Ltd.
24) Before obtaining the above said policy issued by the Opposite Party No.1, Opposite Party No.2 had obtained a proposal form in which the wife of the Complainant has shown no pre-existing disease. It is also on record that as per the endorsement on the policy the policy period was extended from 01/11/05 to 29/04/06 (Extension of 180 days).
25) There is one document on record i.e. the certificate of protection for Health Hospitalization Mutual Scheme, issued by the Opposite Party No.2. this certificate is valid from 30/04/06 to 29/04/07 which is continuation of the endorsement issued by Opposite Party No.1 (as mentioned in para 23 above and annexure ‘D’ to the complaint).
26) The Complainant’s wife was hospitalized between 25/08/06 and 28/08/06 i.e. during the validity of health insurance certificate – Protection Note No.MH/M-30 which is a renewal protection No.250501/46/04/8500618.
27) The main contention of the Opposite Party No.1 is that it is not concerned with the Complainant as the protection note for 2006-2007 was issued by Opposite Party No.2. Therefore, the Complainant and his wife are not its consumer. This contention does not hold water in light of our observation in para 26 above as the protection Note No.MH/M-30 is the renewal of protection 250501/46/04/8500618. Even the Opposite Party No.1 has further stated that Complainant obtained family floater concept with pre-existing without maternity benefit policy from Opposite Party No.2 which is a renewed policy of Policy No.250501/46/04/8500618 issued by itself only. Still Opposite Party No.1 denied its liability.
28) It is further contended by the Opposite Party No.1 that Complainant’s wife suppressed the fact that she was suffering from knee joint at the time of submitting the proposal form. In this case as per the Opposite Parties only she had submitted this form on 28/10/04 (letter of Opposite Party No.2 to the Complainant dtd.02/11/06) and there is no any evidence to show that this ailment was there on or before 28/10/04 or more precisely before 01/11/04 when the 1st mediclaim family floater policy issued by Opposite Party No.1 incepted. The left knee operation was performed on 26/08/06 i.e. more than 1½ years. Therefore, it cannot be said that the insured had suppressed this fact at the time of filling of the proposal form. Therefore, Opposite Party No.1 has taken a very wrong stand to avoid its liability.
29) So far as the Opposite Party No.2 is concerned, Opposite Party No.2 has denied that the policy covered pre-existing disease under the floater risk. In this connection, on the front page of the relevant policy only it is written very conspicuously in a rectangular space as “FAMILY FLOATER CONCEPT WITH PRE-EXISTING WITHOUT MATERNITY & DOMICILIARY BENEFIT”, still the Opposite Party No.2 denies that the policy covered pre-existing disease under the floater risk. This is certainly an absurd averment in order to avoid its liability.
30) Though the Opposite Party No.2 has not referred its own letter dtd.02/11/06 in its written statement, we have carefully gone through the letter of repudiation of Opposite Party No.2 dtd.02/11/06 wherein mainly the claim of the Complainant was repudiated as per condition 5(1). However, the Opposite Parties particularly Opposite Party No.2 has not produced the original copy of the terms and conditions of the insurance protection notes.
31) NIC Policy No.250501/46/04/8500618 is a renewal of Policy No.N/A 11/12/00/4803/09450. This is conspicuously mentioned on the front page of NIC Policy No.250501/46/04/8500618. Still the Opposite Parties are contending that it is not a renewal of the old policy i.e. Policy No.11/1200/4803/04450. This is nothing but misleading the Forum in order to avoid their liability. Therefore, the repudiation as per this letter dtd.02/11/2006 is baseless. The grounds mentioned therein are misleading. Therefore, in our view, both the Opposite Parties are liable for heavy costs and we held them liable for deficiency in service as well as unfair trade practice, in repudiating the legitimate mediclaim of the Complainant. In view of the above observations we pass the following order –
O R D E R
i. Complaint No.57/2008 is partly allowed.
ii Opposite Parties are directed to reimburse jointly and/or severally to the Complainant Rs.2,46,991/- (Rs. Two
Lacs Forty Six Thousand Nine Hundred Ninety One Only) alongwith interest @ 9% p.a. from 02/11/2006 till the
its payment.
iii.Opposite Parties are also directed to pay jointly and/or severally to the Complainant Rs.25,000/-(Rs. Twenty
Five Thousand Only) towards mental agony caused to the Complainant due to the deficiency in service on
the part of Opposite Parties.
iv.Opposite Parties are also directed to pay jointly and/or severally to the Complainant Rs.5,000/- (Rs. Five
Thousand Only) towards the cost of this complaint.
v.Opposite Parties are directed to comply with the above order within 30 days from the receipt of this order.
vi.Certified copies of this order be furnished to the parties free of cost.
