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2010(4) CPR 139 (NC)
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION,
NEW DELHI
Ashok Bhan, President and Mrs. Vineeta Rai Member
P Srinivasulu Chetty —Petitioner
versus
Diners Club International through its DCR Manager and Anr. —Respondents
Revision Petition No. 1923 of 2007
Decided on 10.8.2010
For the Petitioner:Mr. Anil Nauriya, Advocate with Ms. Ruchna Bahadur and Mr. Z.K. Jami, Advocates.
For the Respondent No. 1:Mr. Rahul Malhotra, Advocate.
For the Respondent No. 2:Mr Mohan Babu Aggarwal, Advocate
IMPORTANT POINT
Responsibility for non-renewal of Health Policy cannot rest on Policy-holder alone.
Headnote:Consumer Protection Act, 1986—Sections 2(1)(g), 2(1)(o), 15, 17, 19 and 21—Insurance— Health Policy—Rejection of claim on the ground that renewal form from Petitioner was not received within specified time—Complaint dismissed by District Forum—State Commission upheld order of District Forum to the extent that there was break in Health policy and present policy was a fresh policy—Contention of Respondent that Petitioner’s wife was suffering from pre-existing diseases and was not eligible for reimbursement has not been proved— Repudiation of Mediclaim on grounds of pre-existing diseases by Respondent is without just cause—Responsibility for non-renewal of policy cannot rest on Petitioner alone—Respondents must share blame for not processing request in timely manner , for an old and long standing client—Apart from re-processing medi-claim , Respondent directed to pay sum of Rs.15,000/- as costs to Petitioner. (Paras 6, 8, 13,14, 18 and 19)
(2010) 5 SCC 513—Relied on.
Result: Revision petition dismissed.
Mrs. Vineeta Rai, Member— Aggrieved by the order of the State Commission, the Petitioner in this case Shri P Srinivasulu Chetty has filed aRevision Petition under Section 21 (B) of the Consumer Protection Act, 1986, against M/s Diners Club International and New India Insurance Co. Ltd. (Respondents No.1 and 2 herein)
2. The brief facts of the case according to the Petitioner are as follows:
The Petitioner was a card holder of the Diners Club International since 1983, which was valid upto March 2010. The Diners Club (Respondent No.1) offered a comprehensive family medical insurance programme known as Club Solace, especially for its members as agent of New India Insurance Co. Ltd., (Respondent No. 2). Petitioner took the facility of Club Solace (hereinafter referred to as the ‘Health Policy’) in February 1993 which was renewed every year through Respondent No. 1. In December 1996, the Petitioner wrote to Respondent No. 1 that since he had not received any intimation regarding renewal of the Health Policy for the period February 2000 to January 2001 he requested for the same, since he did not want the policy to lapse. In response, Respondent No. 1 informed him that while processing the application it was found that the card account of the Petitioner needed to be regularized; therefore, they were not in a position to accommodate the application. According to the Petitioner this was a false assertion since, the Petitioner’s account with Respondent No. 1 had been duly renewed. On 03.03.2000, Respondent No.1 again wrote to the Petitioner stating that it was not possible to renew the Health Policy from February 2000, because the renewal form from the Petitioner was not received within the specified time. However, the said Policy was subsequently renewed with effect from April 2000.
3. In May 2000, following the death of his son (in April 2000), his wife P Rajamma was suddenly hospitalized, and the Petitioner spent Rs. 1,90,163/- on her treatment. Since the medical insurance cover under the policy was for Rs.1,10,000/- Petitioner submitted a claim to Respondent No. 1, limited to that amount. In September, 2000, Petitioner also under went a cataract operation on which he spent an amount of Rs. 16,281/-. Claim for this was also sent through Respondent No.1 to Respondent No.2.
4. Respondent No.2 rejected the claim of the Petitioner’s spouse on the following grounds:
“From the copies of previous medi-claim policies submitted we note that the insured was covered under medi-claim policy from 01.02.1993 to 31.01.1994 and from 01.02.1995 to 31.01.2000. The present policy has commenced from 01.04.2000. Since there is break in cover from 01.02.2000 to 31.03.2000, the present policy commencing after the break will be treated as fresh/ first year policy and diseases contracted prior to inception of policy will be treated as pre-existing diseases.
Our medi-claim policy excludes claims arising out of pre-existing disease i.e. diseases existing prior to inception of policy. Since the subject claim is in respect of pre-existing diseases we, regret to inform you that we are unable to entertain your claim”.
5. The claim for the cataract surgery of the Respondent was also repudiated on the grounds that the health policy specifically excluded cataract from being under medical insurance cover.
6. Aggrieved by these actions on the part of Respondent Nos.1 and 2, Petitioner filed a complaint before the District Forum, Chittoor which was dismissed on 04.02.2003.
7. Petitioner thereafter filed an appeal before the State Commission under Section 12 of the CP Act. State Commission in its order inter-alia gave the following findings:
(i) The medi-claim insurance sought by Respondent No. 1 for cataract surgery is specifically excluded as per clause 4 of the medi-claim policy and therefore, the complainant is not entitled to any claim in respect of this surgery.
(ii) Regarding the case of Petitioner’s wife, since the Respondents (on whom there was the onu
