Judgment:
Oral Order:
Per Mr. P.N. Kashalkar, Honble Presiding Judicial Member
1) This is an appeal filed by the original O.P./United India Insurance Company Limited against the judgment and award passed by the South Mumbai District Consumer Forum dated 15/1/2009 whereby while allowing the complaint, the Forum below directed the insurance company to pay Rs.1,19,302.50/- to the complainant with interest at the rate of 9% per annum and Rs.20,000/- towards compensation and cost.
2) Facts to the extent material may be stated as under:
3) Respondent/complainant herein had filed consumer complaint alleging deficiency in service on the part of O.P./insurance company since his mediclaim was repudiated by the insurance company illegally and wrongly. The complainant pleaded that he was continuously purchasing mediclaim policy from O.P. since 15/2/1994 except for a break of 13 days between 15/2/2000 to 27/2/2000. The complainant had suffered chest pain on 7/5/1998 and again on 23/12/1998 for which he was hospitalized and his hospitalization expenses on both occasions were reimbursed by the insurance company. He had renewed the policy after hospitalization every year without any exclusion clause. He pleaded that for the year 2000-2001 he could not purchase policy on the expiry of previous policy and took renewed policy after 13 days break. The policy was issued to him from 28/2/2000 and it was renewed for another year on 28/2/2000. He suffered chest pain on 3/7/2001 for which he was hospitalized and he spent amount of Rs.1,19,302.50/- as expenses of hospitalization. He lodged mediclaim with O.P. But, the O.P. repudiated the claim on the ground that policy was hit by pre existing disease attracting exclusion clause when he renewed policy on 28/2/2000. Aggrieved by the repudiation, he approached the Forum below for redressal of his grievance.
4) In response to notice issued by the Forum below, the O.P. appeared and contested the matter by filing written statement. The O.P. pleaded that complainants cheque dated 15/2/2000 had bounced. Hence, he was served with a notice that said policy had been terminated and that if would pay premium he would be issued new policy as a new contract of insurance. The O.P. pleaded that new policy was issued after payment of premium and the claim lodged by the complainant for hospitalization was referring to Ischemic Heart Disease. The O.P. justified repudiation since the complainant was suffering from I.H.D. for more than two years and it was pre existing disease compared to new policy purchased from 28/2/2000. The Forum below relying on Honble Supreme Court judgment mentioned in the judgment of the Forum held that there was deficiency in service on the part of insurance company. The policy purchased by the complainant was continuation of existing contract of insurance and renewal of insurance policy every year should be on the same terms and conditions as per the original policy initially issued in 1994 to the complainant. Thus, the Forum below found that heart disease excuse put forth by the insurance company was a frivolous excuse given by the insurance company to unjustifiably repudiate the claim. It held that disputed policy was on same terms and conditions as the old policy and it must be considered as renewed and continuous policy (though there was technical break of 13 days as alleged by the insurance company) and turned down the plea of the insurance company that the policy in question was new policy issued by way of new contract. Thus, the Forum below allowed the complaint and passed order as reproduced in para 1 of the judgment. As such, the insurance company has filed this appeal.
5) We heard submissions of Ms.Bindu Jain, Adv. for the appellant and Ms.Rashmi Manne, Adv. for the respondent. We perused the impugned judgment and award passed by the District Forum.
6) We are finding that finding arrived at by the Forum below and the judgment delivered by it are sustainable in law. The Forum below committed no error in allowing the complaint. It is pertinent to note that the complainant had been purchasing mediclaim policy from the appellant company every year without fail by paying requisite premium. Twice his claims were allowed by the insurance company. In Februray-2000, he had issued cheque of premium to renew mediclaim policy in continuation of his previous policy. The said cheque got dishonoured. When insurance company informed about the same, the respondent herein immediately arranged to pay premium in cash and renewed policy from 28/2/2000. So, within 13 days since the previous policy period was over, he had renewed policy for the subsequent year. Simply because there was break of 13 days that doesnt mean that the said renewal of policy for which premium was accepted by the appellant/insurance company was a sort of new contract of insurance. It was the renewal of old existing mediclaim policy by the respondent. The appellants counsel could not show to us in the course of argument from the record that insurance company got filled from the respondent fresh proposal form, had asked for medical certificates, got examined respondent from the panel doctors and then issued the new policy. Had the insurance company gone into these sort of formalities we would have held that the policy issued with effect from 28/2/2000 to the respondent was new contract of insurance. Since these formalities were not gone into, it must be held that it was a renewal policy of existing medical policy though it was delayed by 13 days. In the renewed policy issued by the insurance company to the respondent which was in force from 28/2/2000 to 27/2/2001 it was simply mentioned exclusions would be AIDS. So, if at all respondent would have preferred mediclaim pertaining to his ailment of AIDS, the insurance company would have been justified in repudiating the claim. But they had not mentioned in the exclusion I.H.D. for which twice complainant had lodged claims and insurance company had allowed those claims. So, even as per insurance companys record, I.H.D. was not a pre existing disease as was sought to be argued by Adv.Jain for the insurance company. The said disease was not pre existing disease. It was a new disease respondent suffered and for which twice from 1994-2000 insurance company had paid two claims to the respondent. When this is so when third claim was put forth or lodged by the respondent with the insurance company it wrongfully repudiated the claim citing exclusion clause 4.1. The said clause was not applicable to the facts and circumstances involved in this case. The renewal of policy with effect from 28/2/2000 to 27/2/2001 must be held to be a simply renewal of existing policy and not an altogether new mediclaim policy issued to the respondent herein. So, I.H.D. ailment of respondent was not pre existing disease because the policy in question was renewal of continuous mediclaim policy being purchased by the respondent since 1994. The only exclusion permissible with reference to this policy was ailment of AIDS and nothing else. Therefore, in our view the Forum below was quiet right in allowing the complaint and in passing award in favour of the respondent herein. The Forum below also rightly placed reliance on the judgment of Apex Court and in any view of the matter, the order passed by the Forum below is appearing to be sustainable in law. We are finding no substance in the appeal preferred by the insurance company. As such, we are inclined to pass following order.
Order:
1) Appeal stands dismissed.
2) Parties are left to bear their own costs.
3) Copies of this order be sent to the parties free of cost.