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NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
Prem Narain, Presiding Member
Nirmal Jain —Petitioners
versus
United India Insurance
Company Limited —Respondent
Revision Petition No.1108 of 2015
(Against the Order dated 11/06/2013 in Appeal No. 1035/2010 of the State Commission Madhya Pradesh)
Decided on 27.5.2019
Counsel for the Parties:
For the Petitioner:Mr. Ritesh Khare , Advocate
For the Respondent:Mr. Rajesh K. Gupta, Advocate
IMPORTANT POINTS
1. Petitioner cannot get away by putting all the blame for delay on his counsel.
2. Policy is a contract between the insurer and the insured based on ‘utmost trust’.
3. Terms and conditions of the policy are to be interpreted in the same form as they are mentioned in the policy.
Headnote:
Consumer Protection Act, 1986—Sections 2(1)(r) and 21—Revision—Medi-claim policy—Treatment started within 30 days of the commencement of the policy—Complaint dismissed by State Commission—Revision against—Exclusion Clause No.4.2 is very clear that any treatment taken within 30 days of the commencement of the policy is not admissible under the policy—Huge delay of more than 600 days in filing the present revision petition—It was also the duty of the petitioner to have monitored the progress of the litigation that was pending before the State Commission—Petitioner cannot get away by putting all the blame for delay on his counsel—Reasons for delay as given in the application for condonation of delay are not convincing and cannot be considered as “sufficient cause”—Policy is a contract between the insurer and the insured based on ‘utmost trust’—Terms and conditions of the policy are to be interpreted in the same form as they are mentioned in the policy—Unfair trade practice not proved—Held that, I do not find any illegality, material irregularity or jurisdictional error in the order of the State Commission. [Paras 2, 3, 6, 10, 13, 15, 16 and 18]
Result: Revision dismissed.
ORDER
This revision petition has been filed by the petitioner Nirmal Jain against the order dated 11.6.2013 of the State Consumer Disputes Redressal Commission, Madhya Pradesh, (in short ‘the State Commission’) passed in Appeal No.1035 of 2010.
2. Brief facts of the case are that the petitioner/complainant has taken a medi-claim policy from respondent/opposite party and the same was valid from 29.5.2007 to 28.5.2008. The petitioner/complainant got himself treated for by-pass surgery of heart and was admitted in S.A.L. hospital on 23.6.2007. He was operated on 26.6.2007 and was discharged on 6.7.2007. The claim under the medi-claim insurance was submitted by the complainant after the Insurance Company repudiated on 18.03.2008 and then again on 07.5.2008 the claim was repudiated on two ground that under Clause 4.2 of the exclusion clause, the claim was not admissible as the treatment started within 30 days of the commencement of the policy. The other ground of repudiation was that the claim is not admissible for any pre-existing disease as per the Exclusion Clause No.4.1. The petitioner filed a consumer complaint bearing No.14/2009 before the District Consumer Disputes Redressal Forum, Ratlam, (in short ‘the District Forum’). The complaint was resisted by the opposite party on the same grounds as mentioned in the repudiation letter dated 07.05.2008. The District Forum allowed the complaint and passed the following order on 26.2.2010:-
“15. Hence, by allowing this complaint filed by the complainant against the respondent, order is passed as hereunder:-
a) The respondent is directed to pay the amount of insurance (sum assured) of Rs.1,00,000/- (Rupees one lac only) and interest on the above-mentioned amount of Rs.1,00,000/- at the rate of six percent per annum from the date of dismissing the claim within the period of one month.
b) The respondent is directed to pay the amount of Rs.5,000/- to the complainant against mental agony and pain.
c) Costs of this case of the complainant Rs.2,000/- shall be borne by the respondent.”
3. Being aggrieved, the opposite party/Insurance Company preferred an appeal before the State Commission being Appeal No.1035/2010. The State Commission allowed the appeal and set aside the order of the District Forum vide its order dated 11.06.2013.
4. Hence the present revision petition.
5. Heard the learned counsel for the parties and perused the record. Learned counsel for the petitioner stated that the responsibility to prove the pre-existing disease is on the respondent Insurance Company and the respondent has failed to shoulder this responsibility. No other papers have been filed which supported any pre-existing disease while filing of the proposal form. It was further argued that Exclusion Clause No.4.2 is an unfair trade practice towards the insured on the part of the respondent Insurance Company. When the policy starts from 29.05.2007 the complainant should be allowed to be covered under the policy right from the date of commencement of the policy. The District Forum has rightly allowed the complaint and the State Commission has wrongly accepted the appeal of the respondent/opposite party thereby setting aside the order of the District Forum. The learned counsel further stated that there is delay in filing the present revision petition and the delay has happened because the counsel who was appearing before the State Commission did not inform the complainant in time, rather, he kept the complainant in the dark by saying that the matter was pending before the State Commission. It was requested to condone the delay as the complainant has a strong case on merits.
6. On the other hand, the learned counsel for the respondent Insurance Company stated that Exclusion Clause No.4.2 is very clear that any treatment taken within 30 days of the commencement of the policy is not admissible under the policy. The State Commission has rightly decided the appeal in favour of the opposite party and against the compl
