DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (CENTRAL)

MAHARANA PARTAP BUS TERMINAL: 5^th  FLOOR.

KASHMERE GATE DELHI.

No. DF / Central/ 2015

Rakesh Garg

W/o Ramesh Garg

R/o AK -23 Shalimar Bagh, Delhi

                                    ..........Complainant

Versus

The Oriental Insurance Co. Ltd

A-25/27, Asaf Ali Road,

New Delhi

                                      ..........Respondent/OP

BEFORE

SH. RAKESH KAPOOR, PRESIDENT

SH. S. N. SHUKLA, MEMBER

ORDER

Per Sh. Rakesh Kapoor, President

The complainant and her husband were holding mediclaim insurance policies from M/s New India Insurance Co. Ltd during the year 2008-09.  The policy was valid for the period 25.12.2008 to 25.12.2009. On 25.12.2009 this policy was renewed from OP1 for the period from OP1 for the period 25.12.2009 to 24.12.2010. The policy was further renewed without any break and was in operation till 24.12.2013.   The complainant was admitted in Metro Heart Institute Faridabad and had undergone surgery of the knee. She was discharged on 7.10.2013 and had incurred a sum of Rs 463699.80 as expenses on her treatment.  She had lodged a claim with OP1  which was repudiated on the plea that it was not covered under the terms and conditions of the policy. The complainant  has alleged deficiency  of service on the part of OP1 and has , therefore,   approached this forum for redressal of his grievance.

    OP1 has contested the complaint and has   Preliminary objection no 1  is relevant for the purpose of the disposal of this complaint and is reproduced as under:-

1. At the outset, the present complaint is liable to be dismissed in view of the fact that on scrutiny of the documents, it is observed that the complainant was admitted in Metro Heart Institute on 1-10-2013 with complaints of pain in bilateral knee for six months and difficulty in walking. She was diagnosed as a case of bilateral OA knees with bilateral GENU VARUN PKR (Total Knee Replacement). The said disease is covered after completion of four years of policy, whereas in the present case the policy has completed three years only.  The claim has been repudiated as per exclusion clause 4.1 & 4.3 of the insurance policy. According to clause 4.3 , which says that:-

The expenses on treatment of following ailment/ diseases/ surgeries for the specified periods are not payable if contracted and/ or manifested during the currency of the policy.

Xii joint replacement due to degenerative condition 4 years.”

The repudiation letter dated 15.10.2013 is annexed hereto as Annexure A and the terms and condition of the policy is annexed hereto as Annexure B.

        Op1 has  contested the complaints on merits. It has however not denied that it had issued mediclaim policies to the complainant which were valid upto 24.12.2013. It has also not denied that the complainant was not admitted in the Metro Hospital and had incurred expenses on the treatment of her knee. It was however reiterated that the claim lodged by the complainant was rightly repudiated. It has claimed that the complaint is liable to be dismissed.

    We have heard arguments advanced at the bar and have perused the record.

    The complainant has placed on record a copy of the mediclaim policy which was purchased from M/s New India Insurance Company. This policy was valid for the period 25.12.2008 to 24.12.2009. The complainant has also placed on record copies of polices which were purchased by her from OP1 and were valid for the period 25.12.2009 to 24.12.2010, 25.12.2010 to 24.12.2011 , 25.12.2011 to 24.12.2012 and  from 25.12.2012 to 24.12.2013. It is therefore clear that the complainant was having a mediclaim policy w.e.f. 25.12.2008 continuously without any break till 24.12.2013. The policy was, therefore, more than four years old at the time the complainant fell ill and was treated. The OP has repudiated the claim on the plea that as per exclusion clause no. 4.3 of the policy purchased from it ,a period of four years must pass before the claim can be raised. OP1 has contended that the four year period must be in respect of the policies purchased from it. It has, however, failed to consider a circular of the IRDA dated 14.9.2006 in respect of revised mediclaim policy.

Para 12 of which reads as under:-

If proposal is received for renewal of mediclaim policy of other nationalized / private/ private companies where cumulative bonus confirmation is also available, will the renewal with Oriental be treated as 1^st year policy  where pre-existing diseases exclusion for 1 year/2 years/ 4 years would be applicable?

On renewal of policies of other insurance companies where cumulative bonus is confirmed by the previous insurer the insured will be given the benefit of continuity and pre-existing disease clause will be applied retro respectively for the period for which the cumulative bonus had been allowed. No other discount will however be given, similarly in non benefit will be allowed in fixation of sum insured and waiver of difference of premium, sum insured will be fixed as per the basic sum insured under the expiring policy or as chosen by the insured.      

OP1 has also failed to consider a circular issued by IRDA on 9.9.2011 with respect to Portability of Insurance Policies , relevant portion of which is reproduced as under:-

1.1 Portability : Portability means the right accorded to an individual health insurance policy holder (including family cover) to transfer the credit gained by the insured for pre-existing conditions and time bound exclusions if the policyholder chooses to switch from one insurer to another insurer or from one plan to another plan of the same insurer, provided the previous policy has been maintained without any break.

1.2 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.

In view of the above circular of IRDA , the OP 1 insurance company was not authorized to repudiate the claim lodged by the complainant on the plea that the policies purchased by the complainant from it had not completed four years. It was bound to give the benefit of continuity in policy to the complainant as per the above guidelines of IRDA. We, therefore,, hold that the repudiation of the claim of the complainant by OP1 was an act of deficiency on its part. We, therefore, direct OP1 as under:-

1. Pay to the complainant a sum of Rs. 463699.80 along with interest @ 10% p.a. from the date of institution of this complaint i.e. 9.1.2014 till payment.
2. Pay to the complainant a sum of Rs. 25,000/- as compensation for the pain and agony suffered by the complainant.
3. Pay to the complainant a sum of Rs. 5,000/- 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 belliable to pay interest onthe entire awarded amount @ 10% per annum.  IF the OP fails to comply with thi;s 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.....................

(S N SHUKLA)                        (RAKESH KAPOOR)

     MEMBER                              PRESIDENT