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2004(3) CPR 468
JHARKHAND STATE CONSUMER DISPUTES REDRESSAL COMMISSION, RANCHI
S.N. Mishra, President and Suphal Hansda, Member
Murali Lal Poddar - Appellant
versus
United India Insurance Co. Ltd. & Ors. - Respondents
Appeal No. 4360/2003
Decided on 13.1.2004
For the Appellant:Mr. Biswajit Mukherjee and B. Bhaduri, Advocates.
For the Respondents:Mr. Alok Lal, Advocate.
IMPORTANT POINT
Where mediclaim policy was taken in 1995 and was got renewed continuously till complainant insured suffered heart problem in 2000 and underwent heart surgery in June, 2000, repudiation of claim on ground of suppression of pre-existing disease could not be sustained in law.
Headnote:Consumer Protection Act, 1986 Section 12 and 17 – Mediclaim Policy taken from respondent Co. for 31-3-1998 to 30-3-1999 and was got renewed upto 10-4-2001- Insured complainant was treated for heart problem by Open Heart Surgery for replacement of AORTIC valve in June 2000 - Claim for reimbursement of Rs. 2,41,860/- was declined - Claim was resisted before District Forum on plea that insured had suppressed pre-existing disease while submitting proposal District Forum accepted the plea and dismissed complaint - Appeal- Policy taken from respondent in 1998 was in continuation of earlier policy originally taken in 1995 from Oriental Insurance Company - Respondent Company while issuing policy in 1998 had granted no claim bonus - Respondent thus treated policy in continuation of original policy which had been taken in March 1995 Repudiation of claim on ground of suppression of pre-existing disease could not be sustained in law – Complainant appellant held entitled to reimbursement of bills with 9% interest from date of repudiation of his claim - Rs. 10,000/- awarded as compensation and Rs.1,000/- as cost - Amount if not paid within two weeks of communication of order, interest to be paid at 18% p.a.(Paras 6 to 8)
Result: Appeal allowed.
S.N. Mishra, President- Unsuccessful complainant is the appellant before us in this appeal which arises out of the judgment and order dated 23.7.2003 passed in complaint case No. 49/200 I on the file of the District Consumer Forum, Bokaro, whereby the complainant has been non-suited with respect to the mediclaim under the policy in question.
2. The complainant obtained mediclaim policy on 31.3.1995 under the mediclaim scheme, initially from Oriental Insurance Company Limited being mediclaim policy No. MISC/13441 95-96 for the period from 31.3.1995 to 30.3.1996. The policy was gain renewed on 23.9.1996 covering the period 31.3.1996 to 30.3.1997, which was again renewed for the period from 31.3.1997 to 30.3.1998. The insured, thereafter, switched over to the respondent United India Insurance Co. Limited on 31.3.1998 for the period covering from 31.3.1998 to 30.3.1999 and, thereafter, the said policy was twice renewed for the period upto 10.4.2001. It is alleged that the insured while on business trip to Delhi had a breathing problem and accordingly he was admitted for medical examination on 11.5.2000 in Escort Heart Institute and Research Center, New Delhi where he remained in the said hospital till 12.5.2000. After necessary examination, the insured was discharged with advice to undergo Open Heart Surgery for replacement of ‘AORTIC’ Valve at the earliest. On return from Delhi he immediately informed the Insurance Company vide letter dated 16.5.2000 enclosing the medical expenditure bills for reimbursement of Rs. 15,750/- which, he had incurred. while he was in the hospital. As per the doctor's advice, he was again admitted to the hospital on 19.6.2000 where he has to undergo an Open Heart Surgery. After successful heart surgery, he was discharged from the hospital on 3.7.2000. The insured claimed for total reimbursement of Rs. 2,41,860.45 including the aforesaid Rs. 15,750/ -under the mediclaim policy in question. The Divisional Manager of the respondent Insurance Company vide his letter dated 22.1.2001 expressed his inability to accept the mediclaim resulting the filing of this complaint before the District Consumer Forum, Bokaro, claiming Rs. 4,97,610/- including the compensation and cost of litigation.
3. The Insurance Company appeared and filed their response denying the mediclaim under the exclusion clause of the policy to the effect that the insured has suppressed the pre-existing disease at the time of filing the proposal. The District Consumer Forum has accepted the contention of the Insurance Company and rejected the claim on the ground of suppression of material facts from the Insurance Company at the time of submitting the proposal for obtaining such policy. Aggrieved with the order, the instant appeal was filed before this Commission claiming the reimbursement of medical expenses.
4. Mr. Biswajit Mukherjee, learned Counsel for the appellant has vehemently argued that the reasons assigned while non-suiting the insured for the mediclaim are wholly illegal and unjustified inasmuch as the insured obtained the mediclaim policy initially from the Oriental Insurance Company as far back as in March, 1995, which was continued till 30.3.1998 and, thereafter, the insured switches over to United India Insurance Company which is a sister concern of General Insurance Company of India.
The above said policy was renewed from time-to-time and during the subsistence of the policy, the insured was hospitalised in the Escort Heart Institute and Research Centre in Delhi where he had to undergo open-heart surgery. According to Mr. Mukherjee, the last renewal of the policy, in question, by the respondent Insurance Company was in continuation of the original mediclaim policy obtained from the Oriental Insurance Company. According to Mr. Mukherjee if the last policy issued by the respondent Insurance Company is treated as in continuity of the initial policy. The so-called suppression of pre-existing disease will not arise either. Mr. Mukhe
