The obligation to disclose medical conditions at the time of policy renewal and the applicability of the increased sum insured under the Master Policy.

ORDER

Mr. Narendra Kawde, Member - Aggrieved by the order in consumer complaint bearing no. CC/13/115 decided on 26/08/2014 by South Mumbai District Forum thereby dismissing the consumer complaint, original complainant/appellant [hereinafter to be referred as 'complainant'] has preferred this appeal mainly on the ground that though sum insured under the Master Policy issued by opponent/respondent no.1 [hereinafter to be referred as 'opponent no.1'] to cover the medical expenses of the employees (including their dependent) of original opponent/respondent no.2, LIC of India [hereinafter to be referred as 'opponent no.2']. Only part claim as against the basic sum insured was settled in respect of the medical expenses of the appellant's wife [hereinafter to be referred as 'patient'] and the balance expenditure has not been reimbursed and settled so far. According to the appellant, the learned District Forum did not take into consideration these facts and simply dismissed the consumer complaint by accepting the defence raised by the original opponents which according to him is wrong, illegal and against principle of justice. This appeal has been filed for setting aside the impugned order and allowing the consumer complaint as prayed for.

2. Mr. Ramaswamy Krishnan, the appellant was heard party in person. Learned advocate Mr. J.D. Karanjkar and learned advocate Mr. M.V. Damle for the respondent no.1 and 2 respectively were heard.

3. The dispute between the parties is narrowed down for the release of balance claim of Rs. 80,188/- together with amount of Rs. 50,000/- for mental agony and Rs. 20,000/- towards legal expenses. Mr. Krishnan draw our attention to renewal of Master policy by paying requisite increased premium for the increase sum assured from Rs. 1,65,000/- to Rs. 3 lacs effective from 01/04/2012, the fact which is not in dispute. However, out of Rs. 2,45,188/- incurred on account of medical expenses for treatment his wife. Under the Master Policy amount of Rs. 1,65,000/- has been settled and paid to the complainant which is equal to basic sum assured and balance amount of Rs. 80,188/- has not been paid. Mr. Krishnan submitted that operation for right knee replacement of his wife was carried out on 06/07/2012 i.e. during the validity period of the renewed policy i.e. from 01/04/2012 to 31/03/2013. He has also paid extra premium for increased sum assured which is also not in dispute. The only ground for not settling balance claim of Rs. 80,188/- invoked by the opponent no.1 is that wife of the complainant was suffering from knee pain since last 6 months before surgery. Sum insured was optionally increased to take care of the planned joint knee replacement.

4. It is true that the wife of the complainant consulted the concerned doctor and was hospitalized for period from 25/04/2012 to 28/04/2012 in Holy Spirit Hospital for complaint of pain in low back and pain in (B/L) legs - more in knees. Yet no replacement of knee was recommended by the attending doctor. She was treated and discharged. She was put on physiotherapy later on. It was only on detailed diagnosis through MRI that was carried on 21/05/2012. It was diagnosed as degenerative joint disease - cartilage loss, focal sub-chondral sclerosis and marginal osteophytes. It was thereafter suggested by the attending doctor on 22/05/2012 to undergo for total knee replacement. As advised, patient underwent for replacement of right knee only in July 2012. It was only thereafter the claim under the master policy was raised by the complainant which was partly settled.

5. It is the stand of the opponent no.1 that the balance payment cannot be released even though sum assured was raised to Rs. 3 lacs effective from 01/04/2012. On the ground that earlier four claims under the policy were paid and settled and the complainant was fully aware of planned surgery of knee replacement which he did not disclose at the time of renewal. Opponent no.2 supported submissions of the opponent no.1. N