Tamil Nadu

South Chennai

259/2007

C.Saroja - Complainant(s)

Versus

United India Insurance Co. Ltd, - Opp.Party(s)

V.Balaji

23 Feb 2017

ORDER

                                                                        Date of Filing :   02.08.2006

                                                                        Date of Order :   23.02.2017

DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, CHENNAI (SOUTH)

     2^nd Floor, Frazer Bridge Road, V.O.C. Nagar, Park Town, Chennai-3

 

PRESENT: THIRU. S. PANDIAN, B.Sc., L.L.M.                       : PRESIDENT            

                  TMT. K.AMALA, M.A. L.L.B.,                                 : MEMBER I

             DR. T.PAUL RAJASEKARAN, M.A ,D.Min.PGDHRDI, AIII,BCS : MEMBER II

C.C.NO. 259/2007

THURSDAY THIS  23^rd   DAY OF FEBRUARY 2017

Mrs. C.Saroja,

NO.106, IV Street,

Karpagam Avenue,

Chennai 600 028.                                          .. Complainant.

 

                                   ..Vs..

United India Insurance Co. Ltd.,

Rep. by its Manager,

Divisional Office No.IX,

SMS Complex Near Tel Exchange,

L.B. Road, Adyar,

Chennai 600 020.                                           ..Opposite party.

 

Counsel for the Complainant          :  M/s. V.Balaji  

Counsel for the opposite party       :  M/s. K.S.Narasimhan & another  

 

ORDER

THIRU. S. PANDIAN, PRESIDENT

 

          This complaint has been filed by the complainant against the opposite party under section 12 of the Consumer Protection Act 1986 seeking direction to pay a sum of Rs.67,523.35 & Rs.73,985/- towards medical expenses and also to pay a sum of Rs.1,00,000/- for mental pain and agony suffered by the complainant and also to pay cost of the complaint.

 

1. The averment of the complaint are brief as follows:

         The complainant had taken Medi claim insurance policy with the opposite party for the period from 5.9.2001 to 4.9.2002.  The said insurance coverage was for hospitalization and Domiciliary Hospitalization benefits.   The complainant was  issued a policy bearing No.010900/48/01/03743.  

2.     The complainant fell sick on 2.9.2002 and admitted to Malar Hospital, Chennai for treatment on 8.9.2002 and undergone emergency surgery on 9.9.2002.  With due to her serious health condition and she was not renewed policy.  However within the grace period of seven days from the date of expiry, the said policy has been renewed.   On 9.9.2002 she have renewed the mediclaim policy and the opposite party has renewed earlier policy on 9.9.2002 and issued the renewed policy with earlier policy number for the period of 9.9.2002 to midnight of 8.9.2003.   Again the complainant has undergone revisional surgery on 18.2.2003 for the same ailment at Malar Hospital and discharged on 28.2.2003.  

3.     On 24.9.2002 the complainant lodged the claim in respect of her hospitalization along with discharge summary dated 16.9.2002.   In respect of second hospitalization 18.2.2003 and she lodged to claim on 21.3.2003 along with discharge summary dated 28.2.2003.  But the opposite party has repudiated the both claim on the ground that there is break in policy and revision surgery for the same ailment is not pay as per their panel doctor’s opinion.    The act of the opposite party amounts to unfair trade practice and deficiency of service.   Thereafter the complainant has given representation to the opposite party on 20.4.2003 and 16.2.2004.  But the opposite party has not come forward to settle the claim to the complainant.

4. Written Version of  opposite party is  in brief as follows:

        The opposite party denies all the allegations in the complaint except those that are specifically admitted hereunder.  It is true that the complainant took a medi claim policy for the period 5.9.2001 to 4.9.2002.  It is not admitted that the complainant fell sick on 2.9.2002.  She was unable to renew the policy only due to the fact that she was seriously ill is not a valid reason for failure to renew immediately on the date of expiry of the policy.   It is denied by the opposite party to accept to renew the policy in response to the complainant’s letter.    The issuance of a new policy effective from 9.9.2002 is not related to the previous policy.  

5.     The allegation that the complainant was admitted in hospital from 2.9.2002 is denied.  Even according to the claim form submitted the date of admission is given as 7.9.2002.   As stated above the first policy was for the period 5.9.2001 to 4.9.2002 and as on date of admission, namely 7.9.2002 the same had expired.   A new policy was issued effective from 9.9.2002 to 8.9.2003.   From these facts it is very evident that there was a break in insurance. 

6.     Further Hospitalization on 18.2.2003 to 28.2.2003 was for the same ailment by way of revisional surgery and when the original claim was repudiated the further claim also could not be admitted.   In such circumstances there is no deficiency of service on the part of the opposite party  and hence this complaint is liable to be dismissed.

7.       In order to prove the averments of the complaint, the complainant has filed proof affidavit as her evidence and documents Ex.A1 to Ex.A9 marked.  Proof affidavit of opposite party filed and no document was marked on the side of the opposite party.  

8.   At this juncture, the point for the consideration before this

        Forum is:  

 

 

1.  Whether there is any deficiency of service on the part of the 

     Opposite party as alleged in the complaint?

 

2.  Whether the complainant is entitled to any relief as prayed for?

9.  Point No.1

            Regarding this point on careful perusal of the evidence adduced on both side, it is admitted case that the complainant has taken mediclaim policy for the period from 5.9.2001 to 4.9.2002 which is marked as Ex.A1.  Similarly, the renewed policy Ex.A2 has been issued by the opposite party is not disputed and the same time, it is denied by the opposite party that  the Ex.A2 is not related to the previous policy.  In such circumstances, it is learnt that as per the contract of insurance and relevant statutory provision under insurance act, the policy in question can be renewed within a grace period of seven days.    Admittedly the policy was renewed within five days of expiry.   Hence as rightly pointed out by the learned counsel of the opposite party, the renewed policy is automatically related to original period.  

10.    Moreover, it is pertinent to note that the opposite party has clearly mentioned the first policy No.010900 Ex.A2.  In fact if the second policy is new one, according to the opposite party, it should have assigned new policy number, get fresh proposal form, declaration form etc.  But no such things happened in this case.   Furthermore on seeing Ex.A2 through necked eye, it clearly shows that the risk alone commence from 9.9.2002.

11.    Such being so, it is learnt from the evidence of the complainant that she had fell sick for two occasions i.e. first occasion on 2.9.2002 and was admitted  on 7.9.2002 and discharged on 9.9.2002 from the Malar Hospital and on second occasion she has undergone surgery on 18.2.2003 and discharged on 28.2.2003.   The discharge summary pertaining to both admission in the Hospital of the complainant are marked as Ex.A3 & Ex.A5.   Thereafter, the complainant had submitted her claim form Ex.A4 & Ex.A6 to the opposite party and the same was repudiated on the ground that there is break in policy and revision surgery for the same ailment.   The repudiation letter dated 3.1.2003 is marked as Ex.A7.    In this regard the complainant had given the representation Ex.A8 & Ex.A9.  But the claim was not settled.   

12.    As discussed above, it is needless to say that when the policy was renewed within the grace period of seven days from the date of expiry the policy shall related back to the earlier date.  In this regard, the following  decisions relied upon the learned counsel for the complainant as squarely applicable to the facts of this case on hand.  

National Consumer Disputes Redressal Commission,

       New Delhi

2008 (2) CPR 243 (NC)

Oriental Insurance Co.

..Vs..

Smt. Parkash Devi

 

It is held that

 

The main limb of the argument adduced by the Ld. Counsel for the petitioner is that there was a gap of 55 days between the expiry of the first mediclaim policy and issue of the fresh policy.   The Insurance Company can condone 15 days only not 55 days.  Hence, the orders of the lower fora are erroneous as the policy issued on 17.6.2000 was a fresh policy.   The exclusion clause is very much applicable.

 

SUPREME COURT OF INDIA

V.N. Khare and Shivaraj V. Patil, JJ.

Civil Appeal No.2296 of 2000

Decided on 2^nd August 2001

Biman Kirshna Bose

..Vs..

United India Insurance Co. Ltd and another

Held that

A renewal of an insurance policy means repetition of the original policy.   When renewed, the policy is extended and the renewed policy in the identical terms from a different date of its expiration comes into force.  In common parlance, by renewal, the old policy is revived and it is sort of a substitution of obligations under the old policy unless such policy provides otherwise.  It may be that on renewal, a new contract comes into being, but the said contract is not the same, terms and conditions as that of the original policy.  Where an insurance company which has exclusive privilege to carry on insurance business has refused to renew the mediclaim policy of an insured on extraneous and irrelevant consideration, any disease which an insured had contacted during the period when the policy was not renewed, such disease cannot be covered under a fresh insurance policy in view of the exclusion clause.   The exclusion clause provides that the pre-existing disease would not be covered under the fresh insurance policy.   If we take the view that the  mediclaim policy cannot be renewed with retrospective effect, it would give handle to the insurance company to refuse the renewal of the policy on extraneous consideration thereby deprive the claim of insured for treatment of diseases which have appeared during the relevant time and further deprive the insured for all time to come to cover those diseases under an insurance policy by virtue of the exclusion clause.  This being the disastrous effect of wrongful refusal of renewal of the insurance policy, the mischief and harm done to the insured must be remedied.  We are, therefore, of the view that once it is found that the act of an insurance company was arbitrary in refusing to renew the policy, the policy is required to be renewed with effect from the date when it fee due for its renewal. 

                                III (2005) CPJ 751

ORISSA STATE CONSUMER DISPUTES REDRESSAL

COMMISSION, CUTTACK

NEW INDIA ASSURANCE CO. LTD.

                      .VS..

SK. KARIM AHAMAD & ANR

 

Held that

 

Consumer Protection Act, 1986 – Section 15 – Insurance – Renewal of policy – Premium paid by employer – Extra loading charges collected by company against actual premium amount for renewal of policy – Original  Policy stands renewed with effect from date when it fell due for renewal – Repudiation unjustified – Company liable.

 

In view of what has been stated above, we have no hesitation to hold that as a result of the acceptance of the premium for renewal, the original policy stands renewed with effect from the date when it fell due for its renewal.

 

Furthermore it is pertinent to note that on the side of the opposite party the claim has been repudiated on the ground of the opinion given by the Penal Doctor but in fact neither the opinion of the doctor nor any  affidavit to that effect was filed which clearly shows that there is no truth at all in this aspect.

13.    From the foregoing among other facts and discussion it goes without saying that the repudiation of the claim is unjustifiable and the same cannot be acceptable one.    Therefore the act of the opposite party clearly amounts for unfair trade practice and deficiency of service.   Thus the point  No.1 is answered accordingly. 

14.    POINT No.2

        In view of conclusion arrived in point No.1 the complainant is entitled for the claim amount with interest at the rate of 12% p.a. from  the date of complaint i.e. 2.8.2006 to till the date of this order and reasonable compensation with cost.  Thus the point No.2 is also answered accordingly.

In the result, the complaint is allowed in part.   Accordingly the opposite party is directed to pay a sum of Rs.67,523.35 + Rs.73,985.00 = Rs.1,41,508.35 in toto (Rupees one lakh forty one thousand five hundred and eight and thirty five paisa only) towards two claims made by the complainant for hospitalization and surgery in two occasions with interest at the rate of 12% p.a. from the date of complaint i.e. 2.8.2006 to till the date of this order i.e. 23.2.2017  and also to pay a sum of Rs.10,000/- (Rupees ten thousand only) towards compensation for causing mental agony and hardship due to deficiency of service on the part of opposite party  and to pay a sum of Rs.5000/- (Rupees Five Thousand only) towards cost to the complainant. 

The above amounts shall be payable within six weeks from the date of receipt of the copy of the order, failing which, the said amounts shall carry interest at the rate of 9% p.a till the date of payment.        

         Dictated by the President to the Assistant, taken down, transcribed and computerized by her, corrected by the President and pronounced by us in the open Forum on this the  23^rd   day  of  February 2017.  

 

MBER-I                        MEMBER-II                             PRESIDENT.

 

Complainant’s side documents:

Ex.A1- 5.9.2001    - Copy of Mediclaim policy.

Ex.A2- 9.9.2002    - Copy of Mediclaim policy.

Ex.A3- 16.9.2002  - Copy of Hospital discharge summary.

Ex.A4- 24.9.2002  - Copy of claim form.

Ex.A5- 28.2.2003  - Copy of Hospital discharge summary.

Ex.A6- 21.3.2003  - Copy of claim form.

Ex.A7- 3.4.2003    - Copy of repudiation letter.

Ex.A8- 20.4.2003  - Copy of representation.

Ex.A9- 16.2.2004  - Copy of representation to chairman

Opposite party’s side document: -   .. Nil..

 

 

MEMBER-I                        MEMBER-II                             PRESIDENT.