PER SHRI. S.B.DHUMAL - HON’BLE PRESIDENT :
1) In brief consumer dispute is as under –
That the Complainant had obtained Mediguard Policy from the Opposite Party in the year 2000-2001 sums assured under the said policy for the Complainant was Rs.1 to 2 Lac. Subsequently the policy was renewed regularly and sum insured increased to Rs.2 Lacs to 5 Lacs in the year 2004-05. Alongwith compliant, the Complainant has produced copies of the aforesaid Mediguard Policies.
2) The Complainant, for the year 2000-06 he did not prefer any claim under the Mediguard Policy. The Complainant has produced terms and conditions of Mediguard Policy alongwith complaint and relied upon condition no.4.1.
3) It is submitted that in the year 2007 the Complainant underwent an angiography and Angioplasty costing Rs.4,55,515/- and therefore, he made mediclaim to the Opposite Party as per his entitlement in Clause No.4.1. The Complainant claimed Rs.2 Lacs as per policy and Rs.60,000/- as an accrued cumulative bonus.
4) Opposite Party processed his claim and offered only Rs.1,20,000/- as full and final discharge ignoring provisions of Clause 4.1 in the Mediguard Policy. The Complainant refused to sign Advance Settlement Intimation Voucher for Rs.1,20,0000/-. He wrote letters to the Opposite Party for payment of Rs.2,60,000/- but his requests was not considered by the Opposite Party and therefore, the Complainant has filed this complaint. The Complainant has requested to direct Opposite Party to pay Rs.2 Lacs + Cumulative bonus of Rs.60,000/- i.e. total Rs.2,60,000/- and a further sum equivalent of Rs.93,600/- with interest @ 18% p.a. from 01/10/07 till the date of payment. The Complainant has claimed Rs.50,000/- as damages for harassment and mental agony and cost of this proceeding from the Opposite Party. Alongwith complaint, the Complainant has produced documents as per list of document.
5) Opposite Party has filed written statement and thereby resisted claim of the Complainant contending interalia that complaint is misconceived and deserves to be dismissed with cost. As per Opposite Party, on 01/08/2000 the Complainant submitted Proposal Form for the Mediclaim Insurance Policy and in the said proposal Form the Complainant has admitted that he is suffering from heart disease. Accordingly Opposite Party issued Mediguard Policy for the period 01/08/2000 to 31/07/2001 with an endorsement of Exclusion for self heart disease restricted to only Rs.1 Lac, others 2 Lacs only i.e. sum insured for heart disease was restricted up to Rs.1 Lac only. It is submitted that aforesaid restriction has been in force for over 8 years i.e. from the year 2000-01 to 2007. The aforesaid policy alongwith terms and condition was duly received by the Complainant. The Complainant was aware about the restriction and terms and conditions of the said policy. If the Complainant had any grievance or objection about the terms and condition of the policy he would have informed the Opposite Party. The Opposite Party have produced xerox copies of the Mediguard Policy issued to the Complainant from the year 2000-2007.
6) According to the Opposite Party, there is no deficiency in their service and as per terms and conditions of the policy they had offered Rs.1,20,000/- as full and final settlement (Rs.1 Lac Sum Insured + Rs.20,000/- cumulative bonus) but the Complainant refused to accept the amount. It is contended that there is no cause of action to the complaint and complaint deserves to be dismissed. It is submitted that exclusion written on the policy precedes the terms and conditions which were part of the Policy. The Complainants case does not fall within the purview of Clause No.4.1. They have denied Complainant’s claim of Rs,2,60,000/- and further sum equivalent to Rs.93,600/-. They have disputed Complainant’s claim for interest. According to the Opposite Party, allegations made in the complaint are false and therefore, compliant is liable to be dismissed.
7) The Complainant has filed written argument. Opposite Party has also filed written argument. On 07/04/2011 we heard oral submissions of Complainant and Ld.Advocate Mrs. S.S. Dwivedi for the Opposite Party.
8) Following points arises for our consideration and our findings thereon are as under -
Point No.1 : Whether the Complainant has proved deficiency in service on the part of Opposite Party ?
Findings : No.
Point No.2 : Whether the Complainant is entitled to claim of Rs.2 Lacs + 60,000/- + 93,600/- with interest as claimed ?
Findings : As per final order.
Reasons :-
Point No.1 :- It is admitted fact that the Complainant had obtained Mediguard Insurance Policy for himself and for his family members in the year 2000-01. Opposite Party has produced Proposal Form submitted by the Complainant for the aforesaid Mediguard Policy. In the proposal form itself the Complainant Sanjiv Jhaveri had disclosed that he has heart ailment and for the same he is taking treatment from 26/08/99 from Dr. Bhadresh Shah. In a First Mediclaim Policy issued by Opposite Party to the Complainant for the period of 01/08/2000 to 31/07/01. Sum Insured given to the Complainant Sanjiv Jhaveri is Rs.2 Lacs. There is no endorsement of the policy as follows - “Exclusion for self heart disease restricted to only 1 Lac, other 2 Lac only.” Subsequent policy was issued for the period 01/08/2000 to 31/07/2001 also bears endorsement exclusion of heart disease. 3rd policy for the period 01/08/2007 – 31/07/08 also bears endorsement of heart disease against the name of Complainant. In subsequent policies exclusion of heart disease is noted against the name of Complainant Sanjiv Jhaveri. Last policy is produced on record is for the period 01/08/2007 - 31/07/2008 in which there is also mention of heart disease.
The Complainant has admitted that in the first Mediguard Policy there was exclusion of heart disease and the sum insured for heart disease was restricted to only Rs.1 Lac. However, according to the Complainant, as per Clause No.4.1 “All diseases/injuries which are pre-existing when the cover incepts for the first time. This exclusion will be deleted after 3 consecutive continuous claims free policy year provided, there was no hospitalization for the pre-existing ailment during these 4 years of insurance.” It is submitted that from 2000 to 06 there was no hospitalization and he did not prefer any mediclaim to the Opposite Party so this exclusion heart ailment was deleted after 3 consecutive continuous claim free policy.
On the contrary it is submitted on behalf of Opposite Party that exclusion written in the policy precedes the general terms and conditions of the policy. It is submitted that first policy was given for the period 01/08/2000 – 31/07/01 in which there is specific mention of exclusion heart disease. In the second policy which was for 01/08/01 – 31/08/02 there was mention of exclusion of heart disease against the name of Complainant. In the 3rd policy there was mention of exclusion of heart disease. By referring to the policy dtd.01/08/02 – 31/07/03 it is pointed exclusion of heart disease is only against the name of Complainant. In the Policy for the period 01/07/08 exclusion heart disease was noted. It appears from the aforesaid policy for the period 01/08/06 – 31/08/07 there is exclusion of heart disease and the sum insured for heart disease to the Complainant is restricted Rs.1 Lac and for other disease sum insured is Rs.4 Lac.
The Complainant has not stated the date on which he was admitted in the hospital for angiography and angioplasty. It appears that in the Mediguard policy issued to the Complainant there is specific exclusion of heart disease and sum assured for heart disease is restricted to Rs.1 Lac. Therefore, from the evidence on record, it appears that after receipt of the claim from the Complainant, Opposite Party offered to pay Rs.1,20,000/- to the Complainant as per the terms and conditions of the Mediguard policy issued to the Complainant. In view of the specific endorsement of exclusion of heart disease in the Mediguard policy issued upto to 31/07/08 to the Complainant. We hold that the Complainant is not entitled to get relief under Clause 4.1 of the policy. Hence, we hold that the Complainant has failed to prove deficiency in service on the part of Opposite Party. In the result, we answer point no.1 accordingly.
Point No.2 :- In the year 2007, the Complainant had preferred claim of Rs.4,55,515/- to the Opposite Party under Mediguard policy. Considering the exclusion of heart disease mentioned in the policy, the Opposite Party has rightly offered Rs.1,20,000/- (Rs.1 Lac sum assured and Rs.20,000/- for cumulative bonus) but the Complainant has refused to sign Advance Settlement Intimation Voucher and refused to accept the amount. Considering terms and conditions of the policy, we think it just to direct Opposite Party to pay to the Complainant an amount of Rs.1,20,000/-.
As discussed above, even though aforesaid amount was offered by the Opposite Party to the Complainant, he has refused to accept the amount. Therefore, the Complainant is not entitled to claim interest on the aforesaid amount. The Complainant is also not entitled to claim sum of Rs.93,600/-. Therefore, we direct Opposite Party to pay to the Complainant Rs.1,20,000/-. In the result we answer point no.2 accordingly.
For the reasons discussed above, we pass following order –
O R D E R
i.Complaint No.318/2009 is partly allowed.
ii.Opposite Party is directed to pay an amount of Rs.1,20,000/- (Rs.One Lac Twenty Thousand Only) to the
Complainant within the period from 1 month from the date of receipt of this order.
iii.In case default in making payment of Rs.1,20,000/- to the Complainant within the stipulated period, the
Opposite Party shall be liable to pay interest @ 9 % p.a. on Rs.1,20,000/- from the date of this order.
iv.No order as to cost.
v.Certified copies of this order be furnished to the parties.
