ORDER
Complaint under Sec.12 of the CPA 1986 as amended upto date
Ms. Nipur Chandna, Member
Complainant is the mediclaim policy holder of OP company since 2009.
It is alleged by the complainant that the cheque issued by him for the renewal of the policy was dishonoured and as such he issued another cheque to the OP and accordingly the policy was renewed by the OP vide its policy no. 272601/48/2014/401 w.e.f. 8.5.2013 to 7.5.2014.
It is alleged by the complainant that he got admitted in Stephen’s hospital, Delhi with the complaint of fever, burning micturition, pain in abdomen, dry cough and sugar on 3.2.2014 and was discharged on 12.2.2014.
It is alleged by the complainant that he submitted all the relevant documents with the OP for the reimbursement of his claim, but nothing has been done by OP to settle the same. Hence, this complaint.
Complaint has been contested by the OP . Following Paras of preliminary objection of W.S. are relevant for the disposal of this complaint and the same is reproduced as under:-
It is submitted that aforesaid policy was valid for the period 8.5.2013 to 7.5.2014. Prior to this the complainant was having individual mediclaim policy bearing number 272601/48/2013/167 which was effective for the period 28.4.2012 to 27.4.2013. This policy had expired on 27.4.2013. The complainant opted for a fresh medicalim policy Happy Floater Policy vide policy no. 272601/48/2014/287 for the period 28.4.2013 to 27.04.2014 which was cancelled due to dishonour of premium cheque due to insufficient funds. The complainant again opted for fresh policy as stated hereinabove which was effective only from 8.5.2013 to 7.5.2014. Thus there was a gap of 11 days in both the policies.
The complainant lodged a claim with the respondent for reimbursement of hospitalization expenses incurred by him on his treatment at St. Stephan Hospital for the period 3.2.2014 to 12.2.2014 where he was diagnosed as patient of Type 2 DM (uncontrolled) Chronic Cystitis, UTI, B/L Testacular Atrophy Primary Euthyroid.
On perusal of medical papers ( i.e. Discharge Summary a copy of which is annexed as Annexure R-2 to this reply) it was observed that the complainant was suffering from Uncontrolled Diabetes Mellitus since 4 years and current hospitalization is mainly related to Uncontrolled Diabetes Mellitus and its complication. As stated hereinabove Happy Floater Policy does not cover the expenses incurred for treatment of pre-existing diseases of first four years of inception of insurance vide exclusion clause 4.1 and hence the claim was found be to not payable.
Both the parties have filed their evidence by way of affidavits.
We have heard the arguments advanced at bar and have perused the record.
Counsel for the OP has contended that there is a break in policy as there is a gap of 11 days in the renewal of the policy, He has contended that the Policy has to be treated as a fresh policy.
It is further contended by the counsel for the OP that the claim lodged by the complainant for reimbursement is for the treatment undertaken by him in Stephen hospital mainly for uncontrolled diabetes Mellitus from which he was suffering for the last four years. He has contended that since the policy is a fresh one, the aforesaid disease is excluded for the period of four years as per terms and conditions of the policy.
The Ld. Counsel for the OP has further contended that the OP company had rightly repudiated the claim of the complainant.
Counsel for the complainant on the other hand had has stated that the complainant is a regular subscriber to the mediclaim insurance policy of OP company since the year 2009. He has further stated that the cheque given by the complainant for renewal of the policy was dishonoured and as such a fresh cheque was issued as a result of which the policy was renewed after a gap of 11 days.
It is also stated by the counsel for the complainant that as per the guidelines of IRDA any policy could be renewed after it has lapsed within a period of 30 days and the same would be deemed to be continuation of the earlier policies.
It is further contended by the Ld. Counsel for the complainant that as the policy was a renewed one and was in continuation of the previous policy, the complainant claim is not covered under the ambit of exclusion clause of the policy term and condition, as it is to be considered as a fifth year policy. He has also placed a record the copy of IRDA guidelines in support of his contention.
We are in agreement with the contention of the Ld. Counsel for the complainant. We have gone through the guidelines of IRDA regarding the renewal of the policy. Clause no. f (iv) of the guidelines is relevant and is reproduced as under:-
f. Renewal of Policies
iv The insurer shall provide for a mechanism to condone a delay in renewal up to 30 days from the due date of renewal without deeming such condonation as a break in policy. However coverage need not be available for such period.
In view of the above discussion, and in the lights of the guidelines issued by IRDA, we are of the considered opinion that the policy in question is not to be considered as a fresh policy. It is a renewed policy and is in continuation of the previous policies. Since the policy is running in the fifth year, the exclusion clause of four years as per policy terms and condition was not applicable to the complainants claim.
We are, therefore, constrained to hold that the repudiation of the claim by the OP was unjustified.
We hold OP guilty of deficiency in service and direct it as under:-
- Pay to the complainant a sum of Rs.67,235/- alongwith 10% interest for the date of filing of complaint 22.5.2015 till payment.
- Pay to the complainant a sum of Rs.15,000/- (Rupees Fifteen Thousand only) for pain and mental agony suffered by him.
- Pay to the complainant a sum of Rs.5000/-(Five Thousand only) as cost of litigation.
The OP shall pay this amount within a period of 30 days from the date of this order failing which they shall be liable to pay interest on the entire awarded amount @ 10% per annum. If the OP fails to comply with this order, the complainant may approach this Forum for execution of the order under Section 25/27 of the Consumer Protection Act.
Copy of the order be made available to the parties as per rule.
File be consigned to record room.
Announced in open sitting of the Forum on ___________
