An insurance company can be estopped from relying on an exclusion clause in a policy if the insured has acted in reliance on an oral commitment given by the insurance company.

Mr. Justice B.S. Yadav, Member—This is a Revision Petition against the Order dated the 17th August, 1992 passed by the State Consumer Disputes Redressal Commission, Madras in A.P. No. 250 of 1990 by which the order of District Forum, Madras was set aside and the present Revision Petitioner, M/s. Oriental Insurance Co. Ltd. was ordered to pay Rs : 82,000/- to claimant No. 1 with interest at the rate of 12 per cent per annum from 19th December, 1989 till payment. Costs were also awarded to the claimants.

2. The brief facts are that the complainant No. 2, Mr. A. Samsukani, (Now Respondent No. 2) had taken a med-i-claim policy from the petitioner-company for the period from 14th October, 1988 to 13th October, 1989 for the benefit of his son S.Aliar. However, on the expiry of the said period of the policy it was not renewed immediately. It was renewed after a gap of a couple of days i.e. from 17.10.1989 to 16.10.1990. The said Aliar was admitted in the first Respondent’s hospital i.e. M/s. K.J. Hospital (which was complaint No. 1 in the complainant) on 8th November, 1989 and it was found that he was suffering from Aortic Regurgitation, mild pulmonary Hypertension, Mild Mitral Regurgitation and Rheumatic Etiology. He was advised to undergo Aortic Valve Replacement. The 1st Complainant sent a letter to the Insurance Company to know whether the patient was entitled for reimbursement. There was no. reply and as the matter was urgent the Insurance Company was contacted on phone and the 1st Complainant is alleged to have been informed that the patient was entitled to the benefits under the med-i-claim policy. Consequently, he was operated upon on 9th December, 1989. The Hospital lodged a claim for Rs. 82,000/- under the med-i-claim policy with the Insurance Company. The claim was rejected on the ground that the policy then in force was not a renewed policy but a fresh one and as the illness of the patient occurred within a month from the date of the commencement of the policy, the claim was not maintainable. Aggrieved thereby, the complainants filed the complaint under the Consumer Protection Act, 1986, before the District Forum, Madras claiming Rs. 82,000/- from the Insurance Company.

3. The complaint was contested by the Insurance Company and the main ground was that it was a fresh policy as it was taken after a break of a couple of days on the expiry of the previous policy and, therefore, in view of the exclusion clauses, the Hospital was not entitled to claim under the policy. The Exclusion Clause reads as follows :

“Any Disease suffered by the insured person during the first 30 days from the commencement date of the policy. This exclusion shall not however apply. In the opinion of panel of medical practitioners, constituted by the Company for the purpose, the insured person could not have known the existence of the disease or any symptoms thereof at the time of making the proposal for insurance to the company.

This shall not however apply in case of the insured person having been covered under this scheme with any of the Indian Insurance Companies for a continuous period of 12 months preceding, without any break.”

4. The District Forum held that as the claim of the Complainant has been duly considered by the Insurance Company and thereafter rejected, therefore, there was no deficiency in the rendering of service on the part of the Insurance Company and as such the complaint was not maintainable. Accordingly, the Complaint was rejected. The Complainants were directed to approach Civil Court to get appropriate remedy. Feeling aggrieved against that Order, the complainants filed an appeal before the State Commission. As noticed earlier, the said appeal was accepted and complaint was allowed.

5. Feeling aggrieved of the Order of the State Commission, the Insurance Company has come belore this Commission by preferring this Revision Petition.

6. As this is a Revision Petition we need not discuss the case in detail because it has been lucid