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GOA STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PANAJI
N.A. Britto, President, Vidhya R. Gurav, Member
Tata Aig General Insurance Company Ltd. - Appellant
Versus
Dr. D.J. De Souza - Respondent
F.A. No. 80 of 2014
Decided On : 25-11-2014
Advocate Appeared:
For the Appellant :Mr. V.G. Kurtikar, Advocate.
For the Respondent: In person.
The main legal point established in the judgment is that the terms of an insurance contract must be construed according to their own terms, and the court cannot venture into extra liberalism that may result in rewriting the contract or substituting the terms which were not intended by the parties.
Headnote:
Insurance - Health Insurance Policy - Companies Act, 1956 - Section 3(c)(i) - Section 3(c)(iii)
Fact of the Case:
The complainant filed a consumer complaint to recover a sum of Rs. 2,55,909 plus punitive damages of Rs. 50,000 from two insurance companies. The complaint was allowed by the District Forum, but the appeal was filed by the insurance company.
Finding of the Court:
The court found that the waiting period of two years as provided by Section 3(c) was applicable to the complainant, and the complainant could not claim the benefit of Clause (iii) of Section 3 dealing with exclusions. The court set aside the impugned order and dismissed the complaint.
Issues: The main issue was whether the waiting period of two years applied to the complainant and if the complainant could claim the benefit of Clause (iii) of Section 3 dealing with exclusions.
Ratio Decidendi: The court held that the complainant did not have a retail health insurance policy of an Indian Non Life Insurance Company to be exempted from the waiting period of two years as contemplated by Clause (c)(iii) of Section 3 of the policy dealing with exclusions.
Final Decision: The appeal was allowed, the impugned order was set aside, and the complaint was dismissed. The complainant was ordered to pay a sum of Rs. 1,000 as costs of the appeal to the Consumer Welfare Fund within 30 days.
ORDER :
N.A. Britto, President
The sequence of events which led to the filing of the consumer complaint by the Respondent/Complainant to recover a sum of Rs. 2,55,909 plus punitive damages of Rs. 50,000, from the OPs named therein, and, which has been allowed by the impugned order dated 27.8.2014 of the learned South Goa District Forum at Margao, are as follows:
2. TATA AIG Life Insurance Company Ltd., and TATA AIG General Insurance Company Ltd., are two Companies incorporated under the Companies Act, 1956, having registration Nos. 11-128403 and 11-128425, respectively, of the year 2000, hereinafter referred to as a first and second Company, for the sake of brevity. The name of the first Company has now been changed to TATA AIA Life Insurance Company Ltd. The first Company transacts Life Insurance Business, while the second Company transacts general insurance business.
3. The complainant obtained from the first Company a policy known as “Health Investor” for a period of 10 years by paying a yearly premium of Rs. 28,778 with death benefit of Rs. 1 lac, critical illness benefit of Rs. 1 lac and maturity benefit of Rs. 1 lac. The policy covered 12 critical illnesses including cancer, stroke, heart attack, etc. The complainant paid the premium regularly. The first of such premium was paid on 18.2.2009 and the last of such premium was paid on 14.2.2013.
4. The complainant desired to obtain from the second company a policy known as Medi Prime and as such the complainant filed a proposal form on or about 15.3.2013. The proposal form required the complainant to answer a medical questionnaire and one of the questions which the complainant was required to answer was question No. 5:
5. Have you ever had or has a doctor ever said that you have any of the following conditions/diseases: High blood pressure, diabetes or sugar, any heart related ailment, TB or asthma or breathing problem, tumor or cancer, liver or gall bladder diseases, prostrate, kidney or stone diseases, arthritis or bone disease, blood diseases or disorders, ulcer or stomach disorder, eye or ENT disease, dizziness or fits.
(Emphasis supplied)
5. The complainant answered the said query in the negative.
6. The complainant was issued the said Medi Prime Policy effective from 17.3.2013 by the second Company. The second Company assured the complainant that it would provide the insurance cover detailed in the policy to the insured person up to the sum insured subject to the terms and conditions of this policy based on his statement in the proposal which were incorporated in the policy. Section 3 of the policy document dealt with exclusions and waiting periods as well as specific waiting periods.
7. Section 3(a) provided that the Company would not be liable for any treatment which begins during waiting periods except if any insured person suffers an accident. The specific waiting periods were as follows:
(c) The illnesses and treatments listed below will be covered subject to a waiting period of 2 years as long as in the third Policy Year the Insured Person has been insured under an Medi Prime Policy continuously and without any break:
| (i) | Illnesses: arthritis if non-infective; calculus diseases of gall bladder and urogenital system; cataract; fissure/fistula in anus, hemorrhoids, pilonidal sinus, gastric and duodenal ulcers; gout and rheumatism; internal tumors, cysts, nodules, polyps including breast lumps (each of any kind unless malignant); osteoarthritis and osteoporosis if age related; polycystic ovarian diseases; sinusitis and related disorders and skin tumors unless malignant. |
| (ii) | Treatments: benign ear, nose and throat (ENT) disorders and surgeries (including but not limited to aden oidectomy, mastoidectomy, tonsillectomy and tympanoplasty); dilatation and curettage (D&C); hys-terectomy for menorrhagia or fibromyoma or prolapsed |
