IMPORTANT POINT
Insurance is covenant of good faith.

Dr. S.M. Kantikar, Member—The complainant/petitioner filed this revision petition under Section 21(b) of the Consumer Protection Act, 1986 against the order dated 02-09-2016 in Appeal No.A/14/1010 of the Maharashtra State Consumer Disputes Redressal Commission (for short “the State Commission”) which allowed the appeal filed by OP-1 and dismissed the complaint.

2. The brief facts are that, from year 2001, complainant took a mediclaim policy for a sum assured of Rs.2,00,000/- from New India Assurance Company Ltd. (OP-1). The policy was renewed every year. In the year 2007, the complainant decided to upgrade her policy to the sum of Rs.5,00,000/-. Accordingly, the basic premium was raised from Rs.3,743/- to Rs.7,640/- and the policy was issued which was valid from 16-10-2007 to 15-10-2008. Thereafter, as the complainant was out of Mumbai, she could not renew the policy on time. So, a renewal premium of Rs.6,876/- was paid by her on 19-11-2008. The policy was renewed for the period of 19-11-2008 to 18-11-2009. In May, 2009, she had suffered abdominal pain and heavy bleeding. On 05-06-2009, she underwent a surgery for fibroids of tissues in the uterus at Breach Candy Hospital, Mumbai. She was discharged on 10-06-2009. The complainant incurred Rs.2,09,213.75/- towards hospitalisation expenses. Accordingly, she submitted her mediclaim for reimbursement with the OPs. OP-1 vide letter dated 12-04-2010 repudiated the claim on the ground that, her case falls under exclusion clause. Therefore, being aggrieved by the repudiation, the complainant filed a complaint before the South Mumbai District Consumer Disputes Redressal Forum (for short “the District Forum”) claiming reimbursement of the amount and other reliefs.

3. OP-1 resisted the complaint and filed a written version before the District Forum. OP-2 did not file any written version. The OP-1 submitted that the policy was in force continuously since 2001; but in the year 2008-2009 the policy was renewed with the break of 33 days. Therefore, it was a fresh policy, which excludes the claim for the first two yeaRs.The operation of uterine fibroid is excluded for first two years from the scope of the policy. Therefore, the claim of the complainant was not payable as per the terms & conditions of the policy under clause 4.3. There was no deficiency in service on the part of the OP-1.

4. On the basis of evidence of both the parties, the District Forum partly allowed the complaint and directed the OPs to pay Rs.2,09,214/- to the complainant towards medical reimbursement with interest @ 6% p.a. from 12-04-2010 till realization along with compensation and cost of Rs.20,000/- and Rs.8,000/- respectively. Being aggrieved, OP-1 filed the first appeal before the State Commission, it was allowed and, consequently, the complaint was dismissed. Against the impugned order of the State Commission the complainant filed the instant revision petition.

5. We have heard the learned counsel for both the parties. The counsel for both parties made their submissions as stated in their evidence. We have given our thoughtful consideration. It is an admitted fact that the mediclaim policy was commenced from the year 2001 and it was renewed regularly. On 15-10-2007; the sum assured was upgraded to Rs.5 lakh from Rs.2 lakh and the policy No. 111400/48/06/200/70064 was issued for period of 16.10.2006 to 15.10.2007. It was renewed from 16-10-2007 to 15-10-2008. However, the said policy was not renewed on the date of next renewal i.e. 16-10-2008 but it was renewed on 19-11-2008 for the period from 19-11-2008 to 18-11-2009. Thus, there was a break of 33 days in renewing the policy.

6. Admittedly, the complainant’s policy was in force from 16-10-2007 to 15-10-2008. The next policy was issued by OP was for the period of 19-11-2008 to 18-11-2009; there was a gap of 33 days (16-10-2008 to 18-11-2008). There was no continuity in the policy. The complainant relied upon the previous policy of 2008-2009. The counsel for the OP