Back
2012(1) CPR 34
CHHATTISGARH STATE CONSUMER DISPUTES REDRESSAL COMMISSION, RAIPUR
S.V. Vyas, President; Smt. Veena Misra and V.K. Patil, Members
The Oriental Insurance Co. Ltd. —Appellant
versus
Dr. Deepak Raje —Respondent
Appeal No. 118 of 2011
Decided on 10.10.2011
Counsel for the Parties:
For the Appellant:Shishir Bhandarkar, Advocate.
For the Respondent:Ku. Priyanka Dongre, Advocate.
IMPORTANT POINT
Nobody can add or subtract any condition in policy document after finalization of contract of insurance.
Headnote:(i) Consumer Protection Act, 1986—Sections 15 and 17—Insurance—Mediclaim policy—Treatment for cardiac ailment—Appellant/Insurance Company directed to pay Rs.3,00,000 along with 6% interest , Rs.5,000 as compensation and Rs.1,000 as cost—Only those diseases were excluded, which were pre-existing at the time of taking first Mediclaim—Respondent/complainant was taking insurance cover from appellant/Insurance Company under policy for last 10 years—Neither any condition has been included in policy document nor any written communication was made by the appellant with insured to tell him that if any particular medical condition has been developed in policy period, which may result in claim, then in the event of increase granted in sum insured., will not be available for that particular medical condition—Appeal dismissed. (Paras 8 to 12)
(ii) Insurance Act, 1938—Section 45—Insurance—Contract of insurance is a contract like any other contract—Terms and conditions of insurance policy are binding upon both parties— Nobody can add or subtract any condition in policy document after finalization of contract of insurance, unless there is binding effect of any law or unless both parties give consent regarding exclusion or inclusion of any condition or at least when a policy decision has been taken by Insurance Company, then due information is given to insured. (Para 9)
S. C. Vyas, President—This appeal is directed against the order dated 27.1.2011 of District Consumer Disputes Redressal Forum, Raipur (C.G.) (hereinafter called “District Forum” for short) in Complaint Case No.265/2008, whereby the appellant/Insurance Company, has been directed to pay Rs.3,00,000 to the respondent/ complainant along with interest @ 6% p.a. w.e.f. 6.10.2008 till date of payment and also to pay Rs.5,000 as compensation for mental agony and Rs.1,000 as cost of litigation on account of deficiency in service committed by the Insurance Company in not paying the claim amount of Medi-claim Policy, in respect of Angioplasty and Heart Surgery of the insured/complainant.
2. Briefly stated, facts of the case are that respondent/complainant Dr. Deepak Raje was insured with the appellant/Insurance Company under a Medi-claim Policy for last 10 years continuously. In the year 2007-08, on his request, the sum insured under the Medi-claim Policy was increased to Rs.3,00,000 and premium of Rs.9,664 was accepted by the Insurance Company. In that year, the insured was required to undergo Angioplasty in respect of his cardiac ailment in the hospital situated at New Delhi and he was required to spend about Rs.5,00,000 in the procedure of Angioplasty, admission and treatment in Max Heart & Vascular Hospital, New Delhi. He preferred a claim before the Insurance Company for payment of the amount spent by him for taking treatment in Max Heart and Vascular Hospital, New Delhi, but the Insurance Company had not accepted his claim and proposed to pay Rs.l,00,000 only under the Medi-claim Policy. Alleging it as deficiency in service on the part of the Insurance Company, he filed consumer complaint before the District Forum. Before the District Forum, the defence of the Insurance Company was that at the time of getting insurance cover under the Medi-claim Policy, the complainant was aware of the fact that he was a heart patient. The proposal for increasing sum insured under the Medi-claim Policy was accepted by the Head Office of the Insurance Company and it was informed that the increase would be applicable only in respect of new diseases and not in respect of the diseases, which were already existed. Thus, the complainant was not entitled of getting more amount than Rs.1,00,000, for which he was initially insured.
3. Learned District Forum, after having considered the material placed before it by both parties disagreed with the defence taken by the Insurance Company and allowed the complaint by the impugned order.
4. We have heard arguments advanced by counsel for the appellant in detail and perused the record of the District Forum.
5. Counsel for the appellant/Insurance Company has placed very heavy reliance upon some documents, which were filed by the Insurance Company before the District Forum. Document Annexure OP4, is a Circular dated 8.9.2000, which is available in the record of the District Forum at Page No.74. By this Circular, the Head Office of the appellant/Insurance Company has communicated to all ROs/(CMD SECTI/MSD/ VIGILANCE/REINSURANCE/RID/R&D/JAD/OSTC FARIDABAD/ACCOUNTS regarding Amendment in Medi-claim Policy (Individual and Group) Clarification on Increase in Sum Insured. It has been stated in this Circular that “To ensure that the policy holder do not face any inconvenience the Companies may advise their operating offices as follows:
(i) The sum insured may also be increased under an existing Medi-claim Policy, upto Rs.5,00,000, at the discretion of the operating office by charging pro-rata additional premium for the balance period.
(ii) In case the existing policy excludes any pre-existing disease the same will also apply to the increased sum insured.
(iii) It is of course understood that if the request for increase in the sum insured under an existing policy is received after the Insured has became aware of the development of a medical condition in this policy period which may result in a claim, in which
