The central legal point established in the judgment is the interpretation of the terms and conditions of the mediclaim policy, specifically regarding the renewal of the policy and the applicability of exclusion clauses.

ORDER :

MR. PREM NARAIN, PRESIDING MEMBER

1. This revision petition has been filed by the petitioner, National Insurance Co. Ltd. against the order dated 7.9.2011 of the State Consumer Disputes Redressal commission, Madhya Pradesh (in short ‘the State Commission’) passed in First Appeal No. 952 of 2011.

2. Brief facts of the case are that the respondent had purchased a policy of mediclaim every year since November 24, 2004. During subsistence of the last policy commencing from 17.12.2008, the complainant sustained a heart attack, in which he had to spent a sum of Rs. 1,38,278 but the claim was declined on the ground that continuity between the last policy and the previous policy had not been maintained. Till 27.11.2008 the previous policy was effective but renewal was not done on 28.11.2008. However, a policy was issued on 17.12.2008 on 18.11.2009 the complainant/respondent was detected a known case of CAD, his CAG was done at CH & RC, which revealed LAD Ostium 99% Lession. On 23.11.2009 the complainant/respondent was admitted in the Vishesh Hospital for CABG Surgery. On 27.11.2009, the complainant/respondent underwent surgery and the complainant/respondent after getting over with the treatment was successfully discharged on 7.12.2009. On 12.12.2009, the complainant/respondent submitted a claim under the policy bearing No. 321000/48/08/8500004087 for a sum of Rs. 1,38,278 with the Insurance Company towards the treatment underwent at the hospital and the same was repudiated by the petitioner vide their letter dated 8.2.2010 on the ground that treatment expenses for any diseases contracted within one year of the policy was not payable. The petitioner/opposite party, Insurance Company sent another letter dated 24.2.2010, again repudiating the claim on the ground that pre-existing diseases were not covered under the policy and hence the claim cannot be paid.

3. Aggrieved by the repudiation of claim, the respondent/complainant filed a complaint case No. 38 of 2010 before the District Consumer Disputes Redressal Forum. Khandwa (in short ‘the District Forum’) and the complaint was allowed vide order dated 27.12.2010, which reads as under:

“1. The respondent Insurance Company to make payment of the amount payable to the complainant after disposal of claim of the complainant within 45 days as per the terms of policy.

2. The respondent Insurance Company shall also pay Rs. 500 to the complainant as cost of complaint.”

4. Aggrieved by the order of the District Forum, the petitioner/opposite party Insurance Company preferred an appeal No. 952 of 2011 before the State Commission, which was dismissed vide its order dated 7.9.2011.

5. Hence the present revision petition.

6. Heard the learned Counsel for both the parties and perused the record.

7. The learned Counsel for the petitioner Insurance Company stated that the mediclaim policy was effective from 17.12.2008 till 16.12.2009 and the insured was treated for coronary disease between 23.11.2009 to 7.12.2009. The learned Counsel argued that the claim is not payable on three counts. The first relates to non-admissibility of any claim arising out of the treatment of contracted disease within one year of the commencement of the policy. Second being the Clause 4.1 of the policy which relates to exclusions of pre-existing diseases. In the case history recorded by the treating hospital namely, Vishesh Hospital, as mentioned in discharge summary dated 7.12.2009, it is mentioned that patient is a known case of CAD (detected on 18.11.2009), his CAG was done at CH&RH, which revealed LAD, his Ostium 99% lesion, now patient admitted for CA & BG surgery, DM T2 since 2-3 years (controlled by Yoga), Bronchial Asthma since birth.

8. Thus, it was pointed out by the learned Counsel that the preexisting diseases of CAD, diabetes meilitus (DM) and Bronchial Asthma were pre-existing prior to the date of the inception of the policy. The third point relates to the fact that the insured had given wrong answers to all the ques