This complaint coming up before us for final hearing on 15-10-14 in the presence of Sri M. Sitaramdas, advocate for complainant and of                             Sri K. Bhaskara Rao, advocate for opposite parties, 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

Smt T. Suneetha, Member:-    The complainant filed this complaint                      u/s 12 of the Consumer Protection Act seeking directions on the opposite parties to pay the claim amount of Rs.34,880/- along with interest @24% p.a., from the date of hospitalization and to pay compensation and costs of 35,000/- to the complainant.  

2.   In brief the averments of the complaints are these:

          The complainant obtained Happy Family Floater Mediclaim policies from the opposite party.   Since five years i.e., from 2009 the complainant has been paying premium till 2014.   During the 4^th policy period the complainant underwent laparoscopic hysterectomy surgery on 28-09-12 at Mediline hospital, Mangalagiri Road, Guntur and was discharged on 29-09-12.  The particulars of the policies taken by the complainant are hereunder:

           The complainant submitted all the medical bills and report bills amounting to Rs.34,880/- along with the claim to the 2^nd opposite party through 1^st opposite party.   There was no response from both the opposite parties for about one year.   On repeated requests and reminders the 2^nd opposite party sent mail to the complainant on 18-11-13 repudiating the claim with a reason that hysterectomy operation for the purpose which complainant admitted in the hospital is excluded from the scope of the policy under clause No.4.3 of the terms and conditions of the policy and further intimated to contact the Oriental Insurance Company the policy issuing office for reconsideration in respect of said claim.   The complainant approached the Oriental Insurance Company for reconsideration of TPS opinion.   The insurer stated that the reconsideration of claim is adopted in case of big clients and companies who give good quantum of premium but not the individuals.  

          The complainant hospitalized on 28-09-13 during the 4^th renewal policy period 15-09-12 to 14-09-13 of policy No.463300/48/2013/611 whereas the claim was repudiated on the ground that the claim was excluded from the policy for two years from the date of inception.   The complainant suffered mental agony due to the attitude of the opposite parties which is nothing but deficiency of service on the part of opposite parties.  Hence the complaint.

3. The 2^nd opposite party filed memo adopting the version of the                  1^st opposite party and its contents are as follows:

The complainant is the customer of the Oriental Insurance Company.   The complainant obtained policy on 19-08-09 and continued for two years i.e., upto 18-08-11 and paid premium for the 3^rd year which is  from 15-09-11 to 14-09-12 after delay of 27 days. The complainant obtained the policy on 15-09-11 and continued the same.   As per the terms and conditions of the policy  taken by the complainant on 15-09-11 became a fresh policy.   The complainant took the treatment during the period from 15-09-12 to 14-09-13.The complainant had taken the treatment on 28-09-2012 ie; after one year 14 days of fresh policy .   Under clauses 4.1, 4.2 and 4.3 of the terms and conditions of the policy the complainant is not entitled to claim the amount.   Hence the opposite parties are not liable to compensate the complainant.  

4.      The complainant and opposite parties filed their respective affidavits. Exs.A-1 to A-18 and Ex.B-1 were marked on behalf of the complainant and opposite parties.

5.    The points that arose for consideration in this complaint are these:

          1.  Whether the opposite parties committed deficiency of service?

          2. To what relief?

6.   POINTS 1&2:-    The allegation of the complainant is that the repudiation of her claim by the opposite parties is not justified since she paid all the premiums since 2009 till 2014.   The opposite parties reasoned the repudiation made by them that the complainant’s failure to renew the 3^rd policy within time took away from the entitlement of the claim amount under the policy conditions 4.1, 4.2 and 4.3.  

7.      The terms & conditions from the policy EX-B1 about the renewal of the policy.   Relevant portion is extracted below:

          RENEWAL OF THE POLICY:

a) The Company shall not be responsible or liable for non-renewal of policy due to non-receipt or delayed receipt (i.e. After the due date) of the proposal form or of the medical practitioners report wherever required or due to any other reason whatsoever.

b) Notwithstanding this, however, the decision to accept or reject for coverage any person upon renewal of this insurance shall rest solely with the Company. The company may at its discretion revise the premium rates and / or the terms & condition of the policy every year upon renewal thereof. Renewal of this policy is not automatic; premium due must be paid by the proposer to the company before the due date.

8.      The complainant has paid the 3^rd policy premium with 27 days delay and it is not denied by the complainant in the documents filed by her.   As per the above clause the renewal of the policy is not automatic and the policy holders/complainant is under strict obligation to pay the premium within the policy period if not the policy would be treated as fresh policy thereafter.   There is no availability of grace period for late payment in the policy, in such condition the complainant is under obligation to pay the premium in time without fail to keep her policy in force.  

          Clause No.4.3 in Exclusions of Ex.B-1 is extracted below:   

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

If these diseases are pre-existing at the time of proposal the exclusion no 4.1 for pre-existing condition SHALL be applicable in such cases.

      If the continuity of the renewal is not maintained with the Oriental Insurance Company Limited then subsequent cover will be treated as fresh policy  and clauses 4.1., 4.2, 4 .3 will apply unless agreed by the Company and suitable endorsement passed on the policy.

9.      As per the above exclusions policy no.463300/48/2012/717 period from 15-09-11 to 14-09-12 which is said to have been lapsed policy ,is treated as  fresh policy . Since the insured underwent surgery (on 28-09-2012) after one year and not completing  two years time against   clause no.4.3(ix) the complainant is not entitled to the policy amount .

 10.  In view of the above discussion, the Forum comes to a considered opinion that the complainant’s failure to renew the policy within time have disentitled the complainant from receiving the policy amount .Hence there is no deficiency of service on the part of the opposite party .  The opposite parties are not liable to pay any policy amount and compensation to the complainant.   This point is answered in favor of the opposite party.  

             In the result the complaint is dismissed with out costs.

Typed to my dictation by Junior Steno, corrected by me and pronounced in the open Forum dated this the 29^th day of October, 2014.

MEMBER                                  MEMBER                        PRESIDENT

APPENDIX OF EVIDENCE

DOCUMENTS MARKED

For Complainant:

For opposite parties:    NIL

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.