ORDER               Date: 12th October 2016

Manju Bala Sharma, Member

Relevant facts for the disposal of this complaint filed on 24/02/2015 are that the complainant purchased an Insurance Policy namely ‘’ HAPPY FAMILY FLOATER POLICY’’ from OP on 27-09-2011 for a period of 1 year to cover complainant and his family from accidents and various diseases as per the terms and conditions of the policy.  The complainant got renewed the policy on 01-10-2012 for the period of 01-10-12 to 30-09-2013 with a delay of 04 days in getting the same renewed and the officials of OP told the complainant that since there is a 30 days grace period for renewal the policy the delay of 04 days will not make any difference in the benefit of the policy.  The complainant further got the policy renewed on 01/10/2013 for the period 01/10/2013 to 30/09/2014.  On 13/07/2014 complainant’s father was admitted to Max Devki Hospital for his treatment and was discharged on 15/07/2014.  The complainant intimated the OP about the admission of his father in the Hospital and also filed the claim of Rs. 1,16,688/- (Rs. One Lac Sixteen Thousand Six Hundred Eighty Eight)  forthwith but the same was declined by OP on frivolous grounds.  It is further stated that as per Circular No.  IRDA/HET/MISC/CIR/209/09/2011 dated 09/09/2011 issued by IRDA at para 1.2 states that  :

‘’break in policy:  A break in policy occurs when the premium due on a given policy is not paid on or before the premium renewal date or within 30 days thereof’’. 

It is further stated that the complainant visited the office of OP time and again but OP did not pay any heed to complainants requests.  Pleading deficiency in service on the part of OP the complainant prayed that the sum of Rs. 1,16, 688/- (Rs. One Lac Sixteen Thousand Six Hundred Eighty Eight) the amount spent on the treatment of father of the complainant may be awarded, Rs. 50,000/- (Rs. Fifty Thousand) for causing deficiency of Services, Rs. 50,000/- (Fifty Thousand) as compensation and Rs. 50,000/- (Fifty Thousand) as cost of litigation may be awarded against the OP.

Notice was issued to the OP.  In its reply OP took preliminary objection that there was no deficiency of service on the part of OP and therefore the complaint is not maintainable.  It is admitted by the OP that the complainant obtained the mediclaim policy from OP and on 27-09-2011 to mid night 27-09-2012 and further renewed the same on 01/10/2012 to mid night  30-09-2013 with the delay of 04 days in getting the same renewed and again renewed the same from 01/10/2013 to 30/09/2014.   It is further stated by OP that the complainant admitted in the Hospital for B/L  Inguinal Hernia Surgery within the currency of first two years of policy which is not payable for first Two year of Policy as per clause 4.3 of the Terms & Conditions of the Insurance Policy which reads as under:- 

‘’4.3 The Expenses on treatment of following ailment/diseases/surgeries for the specified period are not payable if contracted and/or manifested during the currency of the policy;

                   i         Surgery of Hernia.  2 years

                   ii        Surgery of Hydrocele.  2 years

                   iii       Non infective Arthritis.  2 years

                   iv       Undescendent Testes.     2 years

                   v        Cataract.  2 Yearsvi Surgery of  benign prostatic hypertrophy. 2

Years.

vi       Hysterectomy for menorrhagia or fibromyoma or myomectomy or prolapse of uterus.  2 Years

                   vii      Fissure/ Fistula in anus.  2 Years

                   viii     Piles.  2 Years  

If the continuity of the renewal is not maintained with the company them subsequent cover shall be treated as fresh policy and clause 4.1, 4.2, 4.3 shall apply unless agreed by the company and suitable endorsement passed on the policy.  Similarly if the sum insured is enhanced subsequent to the inception of the policy, the exclusions 4.1, 4.2 and 4.3 will apply afresh for the enhanced portion of the sum insured for the purpose of this section.

For the purpose of applying this condition, the date of inception of this Mediclaim policy taken from Oriental Insurance Company shall be considered, only payable after 2 continues renewal and without any break in the period of the policy and the said complaint is filed by the complainant under the second year of the policy.’’

It is further stated that as the claim of the complaint filed under the inclusion Clause 4.3 of the policy the same has been repudiated within the purview of the Insurance Policy. 

Both the parties filed their evidence by way of affidavit in support of their case.  Complainant filed copy of the policy dated 27/09/11 Ex CW 1/A, copies of the policies dated 01/10/2012 and 30/09/2013 Ex CW 1/B, copy of the admission slip of the Hospital Ex CW1/C and copy of the circular issued by IRDA Ex CW 1/D in support of his case.  OP has filed copy of the Insurance Policy along with terms and conditions and proposal from Ex R 1 (Colly), copy of the correspondence through e-mail between the regional office and branch office of the OP Ex R2 (Colly), letter of TPA issued on 20/11/2014 and letter dated 28/11/2014 issued by OP to the complainant as EX R3 and R4 respectively in support of its case.        

 We have heard the Learned Counsel for the parties, gone through the written arguments and the documents placed on the file. 

It is an admitted fact that the complainant obtained Insurance Policy namely ‘’Happy Floater Family’’ from the OP for himself and his family for the period from 27/09/2011 to mid night 26/09/2012 and after a gap of 04 days he got it renewed for the period from 01/10/2012 to midnight 30/09/2013 and thereafter on 30/09/2013 Complainant got it renewed for the third consecutive year for the period from 01/10/2013 to 30/09/2014.

          It is contended by Counsel for the OP that as there was a gap of 4 days in renewal of Insurance Policy and no application for condonation of delay was submitted by the Complainant, the gap of 4 days was not condoned and a new Insurance Policy was issued to the Complainant.  To rebut this argument Counsel for the complainant has argued that OP neither asked nor intimated to the complainant to file any application for condonation of delay of 04 days and the fact of delay of 04 days came to the light only when Complainant submitted his claim of Rs. 1,16,688/- (Rs. One Lac Sixteen Thousand Six Hundred Eighty Eight) and the same was closed by the OP as ‘’No Claim’’ communicated to the Complainant vide letter dt : 28/11/2014,  Ex R 4,  the contents of which reads as under :-

‘’AS PER SUBMITTED DOCUMENTS, THERE IS A GAP OF 03  DAYS IN POLICY YEAR 2011-2012 (215100/48/2012/2685) & 2012-13 (215100/48/2013/2996).  THE FAP IS NOT CONDONED FROM THE ORIENTAL INSURANCE CO. LTD. PATIENT ADMITTED FOR B/L INGUINAL HERNIA SURGERY WHICH IS NOT PAYABLE FOR FIRST TWO YEAR OF POLICY AS PER CLAUSE 4.3 (iii).  HENCE THE CLAIM IS NOT ADMISSIBLE UNDER POLICY CLAUSE 4.3.  Accordingly we have closed the above claim treating it as No Claim, which please note.’’

Counsel for the OP has argued that the claim of the Complainant has been repudiated within the purview of the Policy as the claim of the Complainant falls under the exclusion Clause No. 4.3 of policy which is reproduced here under:

‘’4.3 The Expenses on treatment of following ailment/diseases/surgeries for the specified period are not payable if contracted and/or manifested during the currency of the policy;

                    i         Surgery of Hernia.  2 years

                    ii        Surgery of Hydrocele.  2 years

                    iii       Non infective Arthritis.  2 years

                    iv       Undescendent Testes.     2 years

                    v        Cataract.  2 Yearsvi Surgery of  benign prostatic hypertrophy. 2

Years.

vi       Hysterectomy for menorrhagia or fibromyoma or myomectomy or prolapse of uterus.  2 Years

                    vii      Fissure/ Fistula in anus.  2 Years

                    viii     Piles.  2 Years  

If the continuity of the renewal is not maintained with the company them subsequent cover shall be treated as fresh policy and clause 4.1, 4.2, 4.3 shall apply unless agreed by the company and suitable endorsement passed on the policy.  Similarly if the sum insured is enhanced subsequent to the inception of the policy, the exclusions 4.1, 4.2 and 4.3 will apply afresh for the enhanced portion of the sum insured for the purpose of this section.

For the purpose of applying this condition, the date of inception of this Mediclaim policy taken from Oriental Insurance Company shall be considered, only payable after 2 continues renewal and without any break in the period of the policy and the said complaint is filed by the complainant under the second year of the policy.’’

It is argued that as the father of the Complainant was admitted in the Hospital for B/L inguinal Hernia Surgery, Hernia is not payable for first two years as per clause 4.3 of the terms and conditions of the policy and as there was delay of 04 days in getting the policy renewed a new policy was issued to the Complainant on 01/10/2012, hence complainant was not entitled for the claim and the claim was rightly rejected on ‘No Claim’.  To rebut the arguments advanced by counsel for OP, counsel for the complainant has relied upon Circular of IRDA dt. 09/09/2011.  From the perusal of the Circular of IRDA it is crystal clear that break in policy occurs only when premium due on a given policy is not paid on or before the premium renewal date or within 30 days thereof.  In this case the Complainant got renewed the policy with  a gap of  04 days from the date of its actual renewal, therefore, the contention of  lapse of the policy and issuance of new policy raised by OP has no substance.

From the above discussion we are of the opinion that the claim of the Complainant closed by the OP vide its letter dated 28/11/2014 is not justified.      

Holding the OP liable for the deficiency in service we direct the OPs to pay to the complainant a sum of Rs. 1,16, 688/- (Rs. One Lac Sixteen Thousand Six Hundred Eighty Eight) the amount which has been spent on the treatment of father of the complainant, Rs. 20,000/- (Twenty Thousand) as compensation and Rs. 5000/- (Five Thousand) as cost of litigation.

This order shall be complied with by the OPs within a period of 30 days from the date of receipt of this order failing which interest @ 12% shall be payable on the entire above mentioned amount from the date of this order till realisation.  Copy of this order be sent to all the parties free of cost.   File be consigned to Record Room. 

Announced on this   12/10/2016.