IMPORTANT POINT
Whether the insurance premium was paid by the respondent on 3.2.2011 or was it made only on 8.2.2011, is of not serious significance in the matter, in view of the findings of the Insurance Ombudsman on the aspect of contracting of disease. The Ombudsman held that what is material, is the knowledge of contract of the ailment. A mere throat pain cannot be attributed to the knowledge on the part of the complainant that he had contracted a disease. The finding of the Tribunal cannot be said to be unreasonable or biased.

JUDGMENT :

The writ petitioner, a health insurance company challenges Ext.P8 order dated 16.11.2012 in Complaint No.IO/KCH/GI/11-017-566/2011-12 on the file of the Insurance Ombudsman, Kochi. The facts emerging from the pleadings reveal that the respondent had taken a Medi-Classic Health Insurance Policy from the petitioner. Ext.P1 policy was issued to the respondent. The period of insurance was from 8.2.2011 to 7.2.2012. The policy was taken after a preliminary medical examination. The respondent suffered throat pain on 11.3.2011 and was admitted in SUT Royal Hospital, Kochulloor, Trivandrum. He was diagnosed as suffering from Papillary Carcinoma Thyroid and was advised to remove the Thyroid Gland immediately. The respondent underwent a surgery on 16.3.2011.

2. The respondent thereafter made a claim for insurance amount. As the petitioner did not respond, Ext.P2 complaint was preferred by the respondent before the Insurance Ombudsman. The respondent stated before the Insurance Ombudsman that he was approached by the Agent of the insurance company on 2.2.2011, was subjected to medical check up on 3.2.2011 and as and when the formalities were over, the respondent had paid the full premium amount. However, the insurance policy which ought to have been made effective from 3.2.2011 was made effective only from 8.2.2011. The petitioner insurance company is illegally denying insurance to the respondent.

3. The petitioner submitted before the Ombudsman that as per clause 3.2 of Ext.P4 containing conditions of insurance, the petitioner shall not be liable to make any payment under the policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of any disease contracted by the insured person during the first 30 days from the date of commencement of the policy. The petitioner pointed out to the Insurance Ombudsman that Ext.P6 discharge summary would go to show that the respondent was admitted in the hospital on 15.3.2011 and he had a 'swelling front of neck' for 10 days. Therefore, the respondent had symptoms of the disease from 5.3.2011 onwards. This date falls within the excluded period of 30 days from the commencement of the insurance policy. The petitioner further pointed out that in Ext.P7 medical certificate filled in by the treating Doctor, it has been stated that the date of first consultation is 11.3.2011 and 5 days' were given as the period of suffering by the patient prior to the date of consultation. The petitioner pointed out that in fact initially 10 days' was shown in the said medical certificate, which is seen subsequently struck off and made 5 days'. Therefore the disease was contracted by the respondent at least on 5.3.2011. The date clearly falls within the 30 days exclusion period provided under clause 3.2 of Ext.P4. The respondent is therefore not entitled to insurance claim.

4. The learned Ombudsman considered the complaint on the basis of materials provided by the petitioner as well as the respondent. The Ombudsman noted the contentions that the respondent had paid part premium on 3.2.2011 and the balance premium on 8.2.2011. The Ombudsman further noted the contention of the respondent that the entire premium was paid to the insurance Agent on 3.2.2011. However the policy was issued only on 8.2.2011. The Ombudsman noted the legal argument of the respondent that for the delay on the part of the Agent in remitting the insurance premium to the company, which resulted in delayed issuance of policy, the respondent cannot be found fault with.

5. On merits of the claim, the Ombudsman held that the policy commenced on 8.2.2011 and the 30 days waiting period provided under clause 3.2 of the conditions expired on 9.3.2011. As far as contracting of ailment, what is material is knowledge of the contract of ailment. The respondent went to the hospital for consultation merely on the basis of a throat pain and a mere throat pain cannot be attributed as knowledge on the part of the co