No. 7/11.08.2011.

HON’BLE JUSTICE SRI PRABIR KUMAR SAMANTA, PRESIDENT.

Both sides are present through their Ld. Advocates.  This appeal is by the Insurer against the judgement and order thereby allowing the claim case.  Admittedly the Complainant took an Individual Health Insurance Policy which at the relevant point of time was valid for the period from 07.10.2009 till 06.10.2010.  It is also not in dispute that the Complainant had undergone treatment for Fibroid Uterus with Menorrhagia by surgical procedure.  She was admitted to a nursing home namely Medica North Bengal Clinic for the period from 31.01.2010 till 06.02.2010.  The bill for treatment and surgical operation as above was raised for a sum of Rs.39,174/- which was well within the sum insured for Rs.50,000/-.  The case of the Complainant having been settled at Rs.11,476/- the above claim case has been filed.

The Insurer has contested the claim case upon production of Individual Health Insurance Policy that was issued to the Complainant for the priod from 07.10.2009 till the midnight of 06.10.2010.  On the basis of the said policy document it has been contended that the expenses for treatment of the specified illness as disclosed in the said policy document will be restricted to the amount mentioned therein.  In the said policy document the expenses for treatment of Hysterectomy has been restricted to the extent of 20% of the sum assured subject to a maximum of Rs.50,000/-.   Hence it has been contended that the Complainant is not entitled to the exact amount incurred for treatment of Fibroid Uterus with Menorrhagia.

In the case in hand the Complainant took aforesaid Individual Health Insurance Policy w.e.f. 07.10.2005.  The same has been renewed every year without fail upon payment of regular premium by the Complainant.  In the insurance policy covering period from 07.10.2009 till the midnight of 06.10.2010 it has been mentioned as under: “Terms, conditions and clauses attached as per the respective individual schemes”.

“Date of proposal and declaration 07.10.2005”.

In the insurance policy document for the period from 07.10.2005 till 06.10.2007 there was no such clause that expenses for treatment of Hysterectomy would be restricted to 20% of the sum assured subject to a maximum of Rs.50,000/-.  In these state of affairs question has naturally cropped up as to whether the Complainant would be governed by the policy conditions as existed at the time of induction into the Individual Health Insurance Policy in the year 2005 for the period from 07.10.2005 till 06.10.2007.  Evidently this restriction has been put in by the insurance policy for the period from 07.10.2009 till 06.10.2010 which was not in existence in the insurance policy issued to the Complainant for the period from 07.10.2005 till 06.10.2006.  The Health Insurance Policy is valid only for a year unless renewed in the subsequent year by the insured.  It is also a fact that any claim under Health Insurance Policy made for the expenses incurred during the period under policy shall remain valid only for that period and cannot be a valid claim for the subsequent period even if the said Insurance Policy has been renewed in the subsequent year.  Therefore, unless intended by and between the parties the terms and conditions of the Insurance Policy for a particular year would not be valid for the subsequent year even if it is renewed.  In the case in hand the Individual Health Insurance Policy of the Complainant was renewed for the period from 07.10.2009 till the midnight of 06.10.2010 with the terms and conditions and clauses attached as per the respective individual schemes as on the date of proposal and declaration made on 07.10.2005.  Otherwise the question of recording such terms as above would not have arisen.   Because without such insertion an Individual Health Insurance Policy for any particular period would be governed by the terms and conditions as set by the Insurer for that particular period. 

For the reasons as aforesaid we are in agreement with the Forum below that there being no restrictions whatsoever imposed for the expenses incurred for treatment of Hysterectomy at the time of taking of the insurance policy the Complainant would be entitled to the full amount as incurred by her for the treatment of Fibroid Uterus with Menorrhagia as claimed by the Complainant.  Therefore, there is no illegality and infirmity in the impugned judgement and order.  The appeal is accordingly dismissed.