This complaint coming up before us for final hearing on 25-08-14                                in the presence of Sri V.V.Ramanuja Rao, Advocate for the Complainant and   Sri G.Erukala Reddy, Advocate for the opposite parties 1 & 2, the 3^rd opposite party being set exparte, upon perusing the material on record, after hearing both sides and having stood over till this day for consideration this Forum made the following:-

O R D E R

Per Sri A. Hazarath Rao,  President:-      The complainant filed this complaint under section 12 of the Consumer Protection Act seeking  reimbursement of Rs.59,622/- ( being medical expenses); Rs.19,469/- being interest on 59,622/- from 20-11-12 till filing the complaint; Rs.20,000/- mental agony and Rs.5,000/- towards costs of the complaint.   

2.      The averments of the complaint in brief are these. 

The complainant obtained mediclaim policy from the 1^st opposite party bearing No.550504/48/11/8500000304 covering the period from 08-11-2011 to 07-11-2012.  The complainant on 22-10-12 had under gone an operation for “Acute intestinal obstructed umbilical hernia” in Kocher’s institute of medical sciences at Guntur.  The complainant took treatment as inpatient from 22-10-12 to 29-10-12 and incurred Rs.59,622/- for his treatment and for operation.  The complainant on 19-11-12 submitted necessary documents to the opposite parties 1 &3.  The opposite parties 1 & 3 on     17-12-12 requested the complainant to send aetiology of acute intestinal obstruction and supply bifurcation of the bills for two procedures.  The complainant submitted all documents sought by the opposite parties.  The Sr. Divisional Manager of National Insurance Company Limited, Vijayawada on 19-12-13 informed the complainant that his claim was repudiated alleging failure of renewal of policy in time.  The policy is continuous from 22-09-10.  The opposite party ought to have mentioned it as a fresh policy while issuing fresh policy.  The opposite parties’ repudiating the claim is unjust and unreasonable.  The complaint therefore be allowed.                

3.      The 3^rd opposite party remained exparte.

4.      The contention of the opposite parties 1&2 in brief is here under: 

          The complaint is not maintainable either in law or on facts.  The complainant is not a consumer within the purview of Consumer Protection Act.  The complainant/ insured failed to renew the subject health policy in time and there was a gap 45 to 50 days in the policies of between 2010 and 2011.  The 1^st opposite party had taken a fresh proposal in 2011 from the insurer and in the same year and the insured under went hernia operation and claimed reimbursement.  The opposite party repudiated the claim as per clause exception 3.  Rest  of the allegations contra mentioned in the complaint are all false and invented for filing this complaint.       

5.  Exs.A-1 to A-10 on behalf of the complainant and Exs.B-1 to B-5 on behalf of opposite parties 1 & 2 were marked.        

6.   Now the points that arose for consideration in this complaint are:

1.       Whether the opposite parties repudiating complainant’s claim is just and reasonable, if so did not amount to deficiency in service?

2.       Whether the complainant is entitled to claim compensation as sought?

3.       To what relief?

7.   The admitted facts in this case are these. 

1.       The complainant took Baroda health policy from the opposite parties          1 & 2 for the first time on 05-09-09 (Ex.B-1) and subsequently in 2010, from 08-11-11 to 07-11-12 (Ex.B-3); 08-11-12 to 07-11-13 (Ex.B-4) and from 28-11-13 to 27-11-14 (Ex.B-5).   

2.       The present claim of the complainant arose under Ex.A-1 = Ex.B-2.

3.       The complainant submitted his claim along with relevant documents to the opposite parties (Exs.A-2 to A-6). 

4.       Exchange of notices between parties (Ex.A-7 to A-9).

5.       The opposite parties repudiated the complainant’s claim on 19-12-13 (Ex. A-10).   

8.      POINT No.1:- The burden is on the opposite parties to justify repudiation of complainant’s claim.  The relevant portion in Ex.A-10 under which opposite parties repudiated the complainant’s claim is extracted below for better appreciation:

  a). as per the policy under major exclusions :

1.         Benefits for pre existing diseases will not be available for any conditions (s) as defined in the policy until 36 months of continuous Coverage has elapsed since inception of the first policy with us. 

2.         Any hospitalization expenses incurred in the first 30 days from the first commencement date of insurance cover except in case of injury arising out of accident. 

3.         during the 1^st year of operation of insurance cover the expenses on treatment of diseases such as contract, benign, prostatic hypertrophy, and hysterectomy of hemorrhagic, or fibromyoma, hernia, hydrocele, congenital internal disease, fistula in anus, piles, sinusitis and related disorders are not payable.  These diseases, if pre-existing, will be covered only as per provisions of 1 above. 

Since the policy 550504/48/10/85/2017 did not get renewed within time the next policy ( 550504/48/11/85/304) was issued by obtaining fresh proposal.  For all purposes this policy is a fresh policy.  And hence, the above referred 1 and 3 exclusions are very much relevant to the claim and as per these exclusions claim is not payable.  In these circumstances, we regret to inform you that the claim is being repudiated herewith.     

9.     In order to discharge its burden the contesting opposite parties relied on the conditions mentioned in Ex.A-1.  Ex.A-1 is the terms and conditions of Baroda health policy issued by the opposite parties 1&3. Clause 4 of Ex.A-1 deals with exclusions. Clause 4 exclusions of Ex.A-1 is extracted below for better appreciation:

          4.Exclusions: 

     The company shall not liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of

1. Benefits for pre-existing diseases will not be available for any condition(s) as defined in the policy until 36 months of continuous coverage have elapsed since inception of the first policy with us. 
2. Any hospitalization expenses incurred in the first 30 days from the first commencement date of insurance cover except in case of injury arising out of accident.     
3. During the period of twelve months from the date of inception of the policy, the expenses on treatment of diseases such as cataract, benign, prostatic hypertrophy, and hysterectomy for hemorrhagic, or fibromyoma, hernia, hydrocele, congenital internal disease.  Fistula in anus, piles, sinusitis and related disorders are not payable.  These diseases, if preexisting, will be covered only as per the provisions of 4.1 above. 

10.   The complainant in para 3 of his complaint as well as affidavit mentioned that he took Baroda health policy for Rs.1,00,000/- from the 1^st opposite party by paying the requisite premium and the validity of the policy was from 08-11-11 to 07-11-12.  The complainant either in his complainant or in affidavit did not mention his earlier health policies obtained from the opposite parties 1 & 3 in spite of Ex.A-10 reply.  It is not the case of the complainant that Ex.A-1 policy is renewal of earlier policy.  In Ex.A-1 it was mentioned under the caption NB: the benefits for pre-existing disease will accrue only after the completion of 36 months of continuous coverage since the inception of the fist policy with us.  In Ex.A-1 policy itself it was mentioned that the complainant/insured under went hernia operation in 2005.  In view of such circumstances the complainant is under an obligation to mention whether Ex.A-1 policy was renewal of earlier policies and there is continuity or not.  The complainant did not make any such attempt either in his complaint or in affidavit in spite mentioning preexisting disease in Ex-A1. 

11.   Additional conditions were laid down by the said insurer at page 4 of Ex.A-1 and the relevant portion is extracted below for better appreciation:

         The policy may be renewed by mutual consent.  The company shall not however be bound to give notice that it is due for renewal.  In case the policy is not renewed in time due to any exceptional circumstances beyond the physical control of the insured and is to the satisfaction of the company as grace period upto 15 days may be allowed for renewal of the policy without withdrawal of any accrued benefit under the policy.       

12.   In Ex.A-10 policy it was mentioned that there was a gap of 47 days between the policies taken in 2010 and 2011.  Under those circumstances the contention of the insurer that the policy commencing from 08-11-11 to 07-11-12 is a fresh one is having considerable force.  Whether the subject policy is renewal or fresh one the complainant is not entitled for reimbursement in view of afore said exclusion clause narrated supra.  Therefore the insurer is justified in repudiating the policy as per exclusion clauses mentioned in Ex.A-1.  We therefore answer this point against the complainant.     

13    POINT NO.2:- In view of above findings the complainant in our opinion is not entitled to any compensation much less the amount claimed.  We therefore answer this point also against the complainant. 

14.   POINT NO.3:- In view of above findings in the result the complaint is dismissed without costs.   

Typed to my dictation by Junior Stenographer, corrected by us and pronounced in the open Forum dated this the 02^nd day of September, 2014.

MEMBER                              MEMBER                                             PRESIDENT

APPENDIX OF EVIDENCE

DOCUMENTS MARKED

For Complainant:

For opposite parties:-

PRESIDENT

NB:   The parties are required to collect the extra sets within a month after receipt of this order either personally or through their advocate as otherwise the extra sets shall be weeded out.