C.K. Lekhamma, Member.
The case of the complainant is as follows:
The complainant has taken a family medi claim insurance policy of the opposite party. Initial coverage was for Rs. 30,000/-. Thereafter the policy limit enhanced to Rs. 1 lakh each from 2008 onwards. There is no break in the policy from the year 2000 onwards. On 01-02-2009 complainant’s wife Juliana T.K. had high fever and vomiting and was treated in the nearby hospital. Since her condition worsened on 08/02/2009 she was admitted to the Medical Trust Hospital and was diagnosed and treated for Bilateral Pheumonitis, viral encephalitis with hypoxic encephalopathy, Type 2 Diabetes Mellitus and UTI. And she was discharged on 07-03-2009. The medical expenses incurred during hospitalization at Medical Trust Hospital, Cochin-16amounted to Rs. 1,23,412. The opposite party having provided cashless facility. But the opposite party after receipt of the medical bills only paid an amount of Rs. 40,000/- to the hospital. The sum insured was Rs. 1 lakh and the balance amount had to be paid by the complainant. The denial of the remaining legitimate claim amount of Rs. 60,000/- of the complainant is without any legal or valid ground. The opposite party cannot arbitrarily repudiate major portion of the insurance claim under the pretext that complainant’s wife was diagnosed for diabetes. Besides complainant having renewed the insurance policy without break for the last 10 years is entitled for treatment for Diabetes Mellitus also. As per the condition No. 4.3 waiting period of two years was over for specified aliments under terms and conditions of the insurance policy issued by the opposite party. Due to the negligence and deficiency in service on the part of the opposite party, complainant has suffered loss, damages and suffered severe mental agony. This complaint is filed against the opposite party to pay the balance insurance claim of Rs. 60,000/- with 12% interest from 07-03-2009, Rs. 50,000/- for comensation and costs of the proceedings.
2. Version of the opposite party.
The complainant and his family members were covered under the Medi claim Policy issued by the opposite party from 28-01-2007 to 27-01-2008 for sum insured amount of Rs. 30,000/- each. The allegation in the complaint to the effect that the complainant had taken mediclaim insurance policy from the opposite party “without any break from 2000 onwards is not correct and denied. The enhanced sum insured will not be available for an illness, disease, injury already contracted under the preceding policy period.” Similarly in condition No. 9 “The company’s liability in respect of all claims admitted during the period of insurance shall not exceed the sum insured including cumulative bonus. Moreover pre-existing diseases are also excluded from the policy. The nature of the diseases itself prove that it has been manifested prior to the enhanced sum insured. The prior treatment records itself prove that the diseases were pre-existing. On knowing the disease the complainant enhanced the sum insured amount from Rs. 30,000/- to Rs. 1,00,000/- on 28-01-2008. As the complainant had submitted a claim form under the cashless hospitalization scheme through the Hospital authorities and the guaranteed amount under the policy was Rs. 40,000/- and the same was directly paid by the opposite party to the hospital authorities as a full and final settlement. There is no deficiency of service on the part of the opposite party.
3. The complainant and the opposite party represented through the counsel. The complainant examined as PW1, Exts. A1 to A11 were marked on his side. The opposite party adduced only documentary evidence. Exts. B1 to B5 were marked on his side. Both sides filed argument notes. Heard the counsel for the parties.
4. The points that arose for determination are as follows:
i. Whether the complainant is entitled to get Rs. 60,000/- being the balance insurance claim amount pertaining to the treatment of his wife, from the opposite party?
ii. Compensation and costs if any?
5. Points Nos. i&ii. The opposite party contented that the complainant had prior knowledge about the disease of his wife. The pre existing disease is excluded from the policy. According to the opposite party, the contention in the complaint with regard to the continuation of the policy, on 2000 onwards, is to be proved by the complainant.
On perusal of Ext. A5 to A7 and A9, copies of policies, it is evident that the complainant had family medi claim policy with the National Insurance Company 2000 onwards. The policy with them was renewed up to 27-01-2007 thereafter on the very next day i.e., on 28-01-2007, the expiry of the said policy, the complainant had taken Ext. A10 policy with the opposite party. As per Ext. A10, A11 and A2, copies of policies show that there is no breakage of policy till 2010, Ext. B1 to B3 are the one and the same policy copies. Then the question to be decided is that whether the policy with the opposite party is to be considered as the continuation of the earlier policy with National Insurance Company or not?.
It is pertinent to note that both Insurance companies are public Sector undertakings. They are bound to follow the directions issued by General Insurance Corporation and Central Government. They cannot be permitted to create a social condition which would negate all human rights. It was so held by the Hon’ble Supreme Court in United India Insurance Co. Ltd. Vs. Manubai D Gajera (2008) (2) KLT 774 (SC). In view of the said findings we are of the opinion that the present policy with opposite party is in continuation of the earlier policy with National Insurance Company.
One of the contentions of the opposite party is that if the policy is to be renewed with enhanced sum insured, then the restriction is applicable to a fresh policy. In this point the Hon’ble Supreme Court in Bimankrishna Bose Vs. United India Insurance Co. Ltd. And another 2001 (6) SCC 477 held as follows. “ A renewal of an insurance policy means repetition of the original policy. When renewed, the policy is extended and the renewal policy in identical terms from a different date of its expiration comes into force. In common parlance by renewal, the old policy is revived and it is a sort of substitution of obligation under the old policy unless such policy provides otherwise. It may be that on renewal, a new contract come into being, but the said contract is on the same terms and conditions as of that of the original policy”. Evidently the complainant has taken opposite party’s policy on 28-01-2007 clause 4.3 in Ext. A1, copy of the medi claim policy (2007) reads as :
“4.3 Waiting period for specified diseases/ailments/conditions:
From the time of inception of the cover, the policy will not cover the following diseases/ailments/conditions for the duration shown below. This exclusion will be deleted after the duration shown, provided the policy has been continuously renewed with out Company without any break”.
in which under the head “Name of Disease” Sl.Nos. Diabetes militus and its duration shown is Two years. In this case as per Ext. A10, copy of the policy the complainant has taken the opposite party’s policy on 28/01/2007 the hospitalization of the complainant’s wife as per Ext. B5 discharge summary is 08/02/2009. It seems that the two years waiting period mentioned in the clause 4.3 has been over. Moreover in clause 4.3 has been over. Moreover there is no whisper in Ext. B5 discharge summary, that Juliana , wife of the complainant has any pre-history of her present ailment. And there is no evidence before us to show that she had taken any treatment for the present ailment.
In view of the aforementioned reasons we are of the opinion that the complainant is entitled to get the balance claim amount from the opposite party. It is admitted that the opposite party had paid Rs. 40,000/- towards the hospital bill. The complainant is entitled to get the balance claim amount of Rs. 60,000/- from the opposite party.
In the facts and circumstances of the case we are not ordering any compensation. Nevertheless complainant is entitled to get litigation costs from the opposite party since they failed to settle the dispute at the outset.
Accordingly, we partly allow the complaint as follows:
The opposite party shall pay Rs. 60,000/-, being the balance amount of the medi claim insurance to the complainant and also pay Rs. 1,500/- being the litigation costs to the complainant.
The above said order shall be complied with within a period of one month from the date of receipt of a copy of this order failing
which the amount shall carry interest at the rate of 6% p.a. from the date of order till realization.
Pronounced in the open Forum on this the 29th day of July 2011.
