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2008(4) CPR 95(NC)
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
M.B. Shah, President and Dr. P.D. Shenoy, Member
New India Assurance Co. Ltd. —Petitioner
versus
Shri Kashinath Balmukund Marwadi —Respondent
Revision Petition No. 870 of2006
Decided on 11-2-2008
Counsel for the Parties:
For the Petitioner:Mrs. Pankaj Bala Verma, Advocate.
For the Respondent:Mr. N.M. Gorwadkar, Advocate.
IMPORTANT POINT
Clause in Mediclaim Policy that whether insured had knowledge of disease or not even existence of symptoms of disease prior to effective date of Insurance could enable Insurance Co to disown the liability could not be invoked unless there was some positive evidence of suppression of disease.
Headnote:(i) Consumer Protection Act, 1986—Section 12 and 17—Mediclaim Policy—Complainant holding Policy for Rs. One lakh got risk enhanced to Rs. 3 lakhs for next year—He suffered heart stroke and bypass surgery was performed—Claim for Rs. 2,36,606 was settled for
Rs. 72,464 and rest of the claim was repudiated—Consumer complaint for the claim was resisted on plea that enhanced risk policy was obtained suppressing previous Policy when option for enhancement of limits was not available for employees like him—District Forum allowed the claim—State Commission upheld the order—Revision—Risk was got enhanced pursuant to a Circular issued by Office of petitioner itself—Contention that complainant suppressed the fact of previous policy was invalid—Impugned order was not liable to be interfered with. (Para 8)
(ii) Consumer Protection Act, 1986—Section 12 and 17—Mediclaim Policy—Insured suffered heart stroke and underwent bypass surgery—Claim repudiated on ground that while getting risk enhanced in second year insured suppressed material fact of his ailment—No evidence to show any Hospitalisation or outdoor treatment for any disease prior to commencement of policy—Since there were no symptoms, question of linking up symptoms with disease did not arise—Order of lower Fora allowing claim under Policy called for no interference. (Paras 10 & 11)
Result: Revision dismissed.
Dr. P.D. Shenoy, Member—Respondent was the complainant before the District Forum. Complainant, Kashinath Marwadi, was working as Divisional Manager with the petitioner-Insurance Company. He had purchased a Mediclaim Policy from his company for a sum of Rs. 1,00,000/- for the period from 24.05.1997 to 23.05.1998. On 08.01.1998, the petitioner-Insurance Company sent a letter to the complainant and informed him that he could purchase a policy involving Coverage upto Rs. 3,00,000/- as per the Scheme of the petitioner. Accordingly, on 02.03.1998 complainant purchased the policy from the petitioner. On 17.06.1998 complainant suffered heart stroke, hence a bypass surgery was performed at Pune for which he incurred an expenditure of Rs. 2,36,206/-. The complainant preferred claim in terms of the Mediclaim Policy for reimbursement of medical expenses he had incurred in terms of the previous policy and also from the latest policy. They ordered payment of Rs.72,464/- only and the rest of the claim was repudiated.
2. Accordingly, he filed a consumer complaint in the District Consumer Forum Nasik claiming Rs. 2,36,206 + interest @ 24% per annum. This was contested by the Insurance Company stating that the complainant is simply a retired employee and not a consumer. While taking the policy dated 02.03.1998 he had not disclosed the heart ailment he was suffering from, hence the Exclusion Clause was applicable. The Insurance Company further contended that on the very next day of obtaining the Policy on 2.3.21998 he was admitted to Rubby Hall Pune for treatment and as it was within 30 days from the purchase of the policy, he was not entitled to get any compensation as per the conditions of the Mediclaim Policy.
3. On the basis of the pleadings and considering the affidavits and documents on record, the District Forum Nasik allowed the complaint and directed the petitioner to pay an amount of Rs. 2,36,206/- along with interest @ 9% per annum. Aggrieved by the order of the District Forum, the Insurance Company filed an appeal before the State Commission which was dismissed by the State Commission along with cost of Rs.1,000/-. The State Commission also directed that as some amount was already given pending the appeal, on the remaining amount interest @ 9% per annum shall be payable till the date of final payment.
4. Dissatisfied by the order of the State Commission, Insurance Company has filed this revision petition.
5. Learned counsel for the petitioner Mrs. Pankaj Bala Verma submitted that the respondent was given Employees Concession Policy on 24.05.1997 and a fresh policy was given on 02.03.1998. She drew our attention to the circular dated 1st October, 1997 issued by the petitioner company which is related to one time option to go in for Mediclaim Insurance Policy—Retired employees/spouse of retired employees. Clauses 4 and 5 of the same read as under:-
“4. It would be noted that employees who have not completed the age of 75 years are entitled for 64% Group Discount(please compare the premium of our standard individual Mediclaim policy on which this 64% discount is admissible). Needless to mention that 5% S.T. additionally will be chargeable;
5. We may further elucidate that during this one-time option of retired employees/ widows of employees who are below the age of 75 years, will be entitled for 64% Group Discount, the said discount would be continued even after the age of 75 years subject to continuous renewals;”
6. In pursuant of this, the complainant has received a letter from his company. He obtained a fresh policy and as he obtained a fresh policy he should not have suppressed his illness. The learned counsel for the petitioner contended that the complainant himself being a Divisional Manager was very well aware that renewal of this Employee’s Benefit Policy was not available for enhanced limits. Therefore, he suppressed the previous policy and obtained a fresh policy for the period from 2.3.1998 to 1.3.1999 for an insured s
