BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.

Date of filing : 03/06/2010

Date of Order : 28/11/2011

Present :-

Shri. A. Rajesh, President.

Shri. Paul Gomez, Member.

Smt. C.K. Lekhamma, Member.

C.C. No. 331/2010

Between

And

O R D E R

A. Rajesh, President.

1. The facts of the complainant's case are as follows :

The complainant availed a mediclaim policy from the opposite parties in 2001. The said policy is valid upto 22-01-2011. The facts being so, the complaint underwent treatment for prolapsed inter vertebral disc at Medical Trust Hospital, Ernakulam from 07-01-2010 to 13-01-2010. His claim for mediclaim insurance was rejected by the opposite parties. Thus, the complainant caused to issue a lawyer notice to the 2^nd opposite party demanding to pay the insurance claim. They sent a reply stating untenable contentions. Aggrieved by the above act of the opposite parties, the complainant is before us seeking direction against the opposite parties to pay insurance claim of Rs. 92,859/- with interest and costs.

2. The version of the opposite parties :-

The complainant was assigned mediclaim policy initially in the year 2002, which was valid till 2007. Again, the policy was renewed and the same was valid till 2009 and the policy expired on 02-01-2009. Thereafter, the complainant had not renewed the policy in time and after a gap of 21 days the complainant remitted the premium on 23-01-2009. The present policy was valid from 23-01-2009 to 22-01-2010. Since the complainant had renewed the policy after 21 days from the date of expiry of the policy the same is construed as a fresh policy. The treatment of the complainant is excluded from the policy vide clause 4.3 of the policy. There is no deficiency in service on the part of the opposite parties.

3. The complainant was examined as PW1 and Exts. A1 to A8 were marked on his side. No oral evidence was adduced by the opposite parties. Exts. B1 to B5 were marked on their side. Heard the counsel for the parties.

4. The points that arose for consideration are :-

1. Whether the complainant is entitled to get the insurance claim from the opposite parties?

2. Whether the opposite parties are liable to pay costs of the proceedings?

5. Point No. i. :- Admittedly, the complainant had been holding insurance policy of the opposite party for the period from 2002 to 02-01-2009 without break received from time to time. The subsequent policy was valid from 23-01-2009 to 22-01-2010. According to the opposite party, the complainant had received the policy after a gap of 21 days and the same is construed as a fresh policy. The opposite party has repudiated the claim application of the complainant by Ext. A7 letter dated 05-04-2010, which reads as follows :

“We have reviewed your claim file. We regret to inform you that we are unable to settle your claim for the reasons given below:

The preceeding policy to the subject policy has expired on 01-02-2009. The current policy bearing no 570101/48/08/8500001031 for the policy period from 23-01-2009 to 22-01-2010, on which a claim has been preferred by the insured, was taken after 20 days on submission of fresh proposal form.

As per the policy conditions, one has to renew the policy within 7 days from the date of expiry of the policy, failing which the policy is construed as fresh one and all exclusions will apply.

Therefore, we concur with the decision of our operating office in repudiating the claim.”

6. Clause 4.3 of the policy reads as follows :

“During the first one year of the operation of the policy the expenses on treatment of Benign ENT disorders & surgeries like Tonsilectomy/Adenoidectomy/Mastoidectomy/Tympanoplasty.

Treatment of diseases such as Cataract, benign Prostatic Hype trophy, Hysterectomy, Hernia, Hydrocele, Congenital Internal Diseases, Fissures/Fistula in anus, Piles, Sinusitis and related disorders, polycystic ovarian diseases, Non-infective arthritis, Undiscended testis, Surgery of gall bladder & bite duct excluding malignancy, Surgery of Genito-urinary system excluding malignancy, Pilonidal Sinus, Gout & Rheumatism, Hypertension, Diabetes, Calculus diseases, Surgery for prolapsed intervertebral disc unless arising from accident, surgery of varicose veins are not payable for first two years of operation of the policy.

Treatment for Joint replacement due to degenerative conditions. Age related osteoarthritis and osteoporosis are not payable for first four years of operation of the policy.

If these diseases are pre-existing at the time of proposal, will be covered only after four continuous claim free policy years.

Note : If continuity of cover is not maintained with National Insurance Company Limited subsequent cover will be treated as fresh for application of clauses 4.1, 4.2 & 4.3 above.”

7. In the instant case, the complainant had to undergo treatment and did the same for the period from 07-01-2010 to 13-01-2010 which is within the currency of Ext. A8 policy. However, the policy was renewed only after a gap of 21 days and which had to be and is construed as new policy as per norms and exclusion clause 4.3 of the policy squarely applies in this case. The complainant having been squarely uncontroverted, he has no room further to controvert in our opinion. However, law permits further interference if at all the complainant substantiates his contention in appeal.

Pronounced in open Forum on this the 28^th day of November 2011.

Sd/- A. Rajesh, President.

Sd/- Paul Gomez, Member.

Sd/- C.K. Lekhamma, Member.

Forwarded/By Order,

Senior Superintendent.

A P P E N D I X

Complainant's Exhibits :-

Opposite party's Exhibits :-

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