| ORDER | KERALA STATE CONSUMER DISPUTES REDRESSALCOMMISSION VAZHUTHACAUD, THIRUVANANTHAPURAM. APPEAL 264/2011JUDGMENT DATED 15.11.2011 PRESENT:- JUSTICE SHRI.K.R.UDAYABHANU : PRESIDENT APPELLANT New India Assurance Company Ltd., 741/A Opp. New Municipal Bus Stand, Tripunithura 682 301 (Rep. by Adv. Sri. Rajan P Kaliyath) Vs RESPONDENTS 1. Cherian P.J., Pulparakuzhiyil House, Chottanikkara Post, Pin 682 312. 2. Medi Assist India Pvt. Ltd., 3rd Floor, No. 49, 1st Main road, Sarakki Industrial Layout, J.P. Nagar, 3rd stage, Bangalore – 560 078. (R1 Rep. by Adv. Sri. Tom Joseph) JUDGMENT JUSTICE SHRI.K.R.UDAYABHANU : PRESIDENT The appellants are the opposite parties/New India Assurance Company in CC. 20/09 in the file of CDRF, Ernakulam. The appellants are under orders to pay a sum of Rs. 20,000/- to the complainants. The case of the complainant, the holder of a Medi Claim policy is with respect to the treatment undertaken by him on P.V. S. Memorial Hospital, Kochi from 28.11.2008 to 16.12.2008 for hyperplasia of prostate. He had incurred a sum of Rs. 43,014/- and the opposite parties provided cashless facility only for a sum of Rs. 23,000/- Originally the policy coverage was for a sum of Rs. 20,000/- The same was enhanced to Rs. One lakh from 14.12.2007. It is the contention of the opposite parties that for the particular illness there is no coverage for 2 years from the date of commencement of the policy. Hence with respect to the enhanced sum, the particular illness is excluded from the coverage. All the same as he had availed an earlier policy with coverage of Rs. 20,000/- the claim was settled for Rs. 23,000/- as he was also entitled for the cumulative bonus of Rs. 3,000/- According to the opposite parties the complainant is not entitled for any further sum. The evidence adduced consisted of the testimony of Pw1, Exts. A1, A2 and B1 to B3. The decision in Biman Krishna Bose Vs. United India Insurance Company Ltd and another 2001 6 SCC 477 wherein Apex court has held that the renewal of the policy meant that the original policy is extended in identical terms from different dates of its expiration was relied only the Forum to uphold the case of the complainant. The counsel for the appellants/opposite parties has pointed out that Supreme Court in the above decision specifically mentioned that the above fact will be so unless such policy provides otherwise. It is pointed out that in Ext. B3 policy conditions it is specified in Clause VI that if the policy is to be renewed for enhanced sum insured the restriction as applicable to a fresh policy will apply to additional sum insured as if a separate policy has been issued for the difference. It is further mentioned that already enhanced the sum assured will not be available for an illness, decease injury, contracted under the preceding policy period. Clause 4.3 mentions benign postate hypertrophy as one of the illnesses for which the policy will not cover for a particular period. The above mentioned illness is excluded for a period of 2 years. We find that the above aspect has not been considered by the Forum in the order. The date of commencement of the policy with enhanced coverage is from 14.12.2007. The complainant underwent the treatment from 28.11.2008. Hence the treatment period is within 2 years of the commencement of the renewed policy with enhanced coverage of Rs. 1,00,000/- Hence we find that the restriction as per Clause VI © of the conditions of policy squarely applies. Hence the complainant will not be entitled for any further sum other than the sum insured with respect to the pre existing policy. Hence the opposite parties/appellants will not be liable to pay any further amount. The order of the Forum in this regard is set aside. In the result, the appeal is allowed. The office is directed to forward the LCR to the Forum along with the copy of this order. JUSTICE SHRI. K.R. UDAYABHANU ; PRESIDENT ST | |
