Oral Order (R. Lakshminarasimha Rao, Member)
1. The unsuccessful complainant is the appellant. The appellant obtained Medi Claim Insurance Policy bearing No.4333011/07/196 for the year 2006 with Oriental Insurance Co., Ltd., Tenali, Guntur District. On 25.10.2006 the appellant underwent bypass surgery in Usha Mullapudi Cardiac Centre, Hyderabad by incurring an amount of `1,50,000/- and intimated the same to the respondent no.2 through fax messages. There was no response from the respondent no.2. After the appellant’s surgery on 6.11.2006, the appellant submitted claim along with required papers with the opposite parties. On 14.2.2007 the appellant got issued a notice to the respondent no.2 to settle the claim. The respondent no.2 even after receipt of claim and notice did not settle it.
2. The respondent no.2 resisted the case contending that the appellant previously obtained policy on 0709-2004 for a period of one year ending with 06-09-2005. After expiry of the policy period he took another policy on 10-09-2005 ending with 09-09-2006. There was delay of 3 days in obtaining the policy. The policy obtained on 10-09-2005 is deemed to be a fresh policy as per the terms and conditions of the policy (i.e. Good Health Insurance Policy – Individuals – under the Head Exclusions 2.1.1 – i.e. policy with Oriental Insurance Co., immediately preceding 48 months without any break. As there was a gap in obtaining the policy on 10-09-2005 for a period of one year ending with 09-09-2006, the appellant is not entitled to claim any claim towards compensation from the respondent no.2. The appellant was diabetic for 15 years which he suppressed and obtained the policy from the insurer. The bills filed by the appellant are not genuine, they are brought into existence in collusion with the hospital and doctors to get more compensation from the respondent no.2.
3. The complainant filed his affidavit and the documents, Exs.A1 to A7. On behalf of the respondent no.2, its Divisional Manager filed his affidavit and the documents, Exs.B1 and B2.
4. As the respondents remained exparte, the District Forum passed an order in CC No.429 of 2009 on 12.09.2007 directing the respondent no.2 to pay an amount of `1,50,000/- towards policy amount and costs of `1500/-. Aggrieved by the order, the respondents filed F.A.No.1058 of 2010 wherein this Commission by its order dated 30.05.2012 set aside the order of the District Forum and remitted back the matter to the District Forum.
5. The District Forum dismissed the complaint on the premise that the appellant suppressed the material fact that he was suffering from diabetes since 15 years.
6. The learned counsel for the appellant the respondent no.1 have filed written arguments.
7. The points for consideration are:
i) Whether the repudiation of the claim is bad?
ii) To what relief?
8. POINT NO.1: The appellant obtained Mediclaim Insurance Policy bearing no.No.4333011/07/196 for one year from 10.09.2006 to 09.09.2007 and he had undergone bypass surgery at Usha Mullapudi Cardiac Centre, Hyderabad on 25.10.2006. The appellant intimated the respondents about the proposed bypass surgery and submitted claim with the respondents on 6.11.2006 and as the claim was not settled, the appellant got issued notice through his advocate on 14.02.2007 to the respondents.
9. The respondent no.2-insurance company repudiated the claim on the premise that 'the policy is not in continuation as there is a gap of 3(three) days in obtaining the policy dated 10.09.2005, as the previous policy ends on 06.09.2005, and the policy obtained on 10.09.2005, as the previous policy ends on 06.09.2005 and the policy obtained on 10.09.2005 was to be treated as fresh policy, hence the complainant suppressed the material facts and he is not entitled for the claim amount'. Thus, the only dispute between the parties is as to computation of the period for the purpose of consideration whether the insurance policy is a fresh policy or it is in continuation with the previous policy.
10. The learned counsel for the appellant has contended that as per the terms of the insurance policy, breaking up period can be condoned upto 7 days and in the case of the appellant, the breaking up period is three days and by condoning the delay of three days and considering the policy as in continuation with the previous policy, the claim ought to have been settled by the respondent no.2-insurance company and that the District Forum failed to consider the decision of the Hon’ble National Commission reported in 1997 III CPJ 332 .
11. The discharge summary issued by Usha Mullapudi Cardiac Centre Hyderabad indicates that the appellant had undergone bypass surgery on 19.06.2006 and he was discharged on 22.6.2006.
12. The appellant in continuation to the insurance policies previously obtained from the respondent no.2-insurance company, he obtained the insurance policy on 7.09.2004 for a period of one year ending with 6.09.2005 and he took the insurance policy on 10.09.2005 for a period of one year ending with 9.09.2006. According to the respondents, the mediclaim insurance policy obtained for the period from 10.09.2005 to 9.09.2006 is a fresh policy since there has been a gap of three days for the commencement of policy dated 10.09.2005. As per the contention of the learned counsel for the appellant, it is not a fresh policy in view of grace period provided for treating a medclaim insurance policy obtained within a period of seven days of expiry of the previous mediclaim policy.
13. The respondent no.2 insurance company repudiated the claim on the premise that the insurance policy in question is not a renewed insurance policy and in view of gap of three days in obtaining the insurance policy dated 10.9.2005, it cannot be treated as fresh policy. The respondent no.2 has filed Ex.B1, the terms and conditions of Good Health Insurance Policy-Individuals. A perusal of condition No.2.1.1 of Ex.B1 goes to show that the premium has to be paid for obtaining renewed insurance policy either in advance or on the date of expiry of the existing mediclaim insurance policy.
14. Admittedly, the appellant has paid the premium three days after expiry of the mediclaim policy obtained for the period from 07.09.2004 to 06.09.2005 and as such the policy in question which was issued on 10.09.2005 cannot be considered as in continuation to the previous mediclaim policy. In the circumstances, the appellant who is eligible to claim for reimbursement of the medical expenses incurred for the medical treatment he had undergone at Ushamullapudi Cardiac Centre only where the mediclaim insurance policy is in existence in continuation of the previous mediclaim policy.
15. The learned counsel for the appellant has relied upon the decision of this Commission in 'Divisional Manager, LIC of India and others Vs T.Venkateshwarlu' III (1997) CPJ 332 wherein this Commission dealt with the case of repudiation of the claim that arose owing to the death of the insured which occurred within six months from the date of commencement of life insurance policy. This commission held that there was no nexus between the abdominal TB suppressed by the insured and the cause of his death. The decision is not of any help to the case of the appellant as the facts of the case and the instant case are totally different.
16. The learned counsel for the respondent no.1 has contended that the respondent no.1 is the facilitator in the matter of facilitating the insured as regards his admission in the hospital for cashless facility or for reimbursement of medical expenses incurred by the insured for the treatment he had undergone during currency of the mediclaim policy. He has relied upon the following decisions:
1. LIC Vs Rajiv Kumar AIR 2005 (SC) 3087
2. Bharat Motors Vs Usha Rani Samal & Anr II (2006) CPJ 119
3. Director General of Police, Chandigarh and Anr Vs Jeevan II(2008) CPJ, 336 (NC)
4. Road Safety Club Pvt. Ltd., Vs Smt Kodi Lakshmi Naray
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annamma and Ors in R.P.NO.191 of 2009 5. The Oriental Insurance Co.Ltd., Vs M.Rangamma and others in F.A.No.1675 of 2007 17. There is no quarrel with regard to the role of the respondent no.1 and the liability of the respondent no.2 to pay the amount if any, to the appellant. The respondent no.1 being a facilitator cannot be fastened with any liability in the matter of reimbursement of the medical expenses under mediclaim insurance policy. 18. Though the District Forum has dismissed the complaint on the premise of suppression of pre-existing disease, repudiation of the claim being made on the foot of fresh policy, this Commission does not find any material showing the repudiation unsustainable. The appeal as such is liable to be dismissed. 19. In the result the appeal is dismissed confirming the order of the District Forum. There shall be no order as to costs.