Oral:The complainant / petitioner company obtained a Group Insurance Mediclaim Policy which covered the illness of its employees from the respondent. An employee of the company, namely, Mr. Khalid Khan got ill and was hospitalized on 28.8.2014. Under the insurance policy which the petitioner company had taken from the respondent, the claim in respect of the expenditure incurred on the treatment was covered to the extent of Rs.3 lakhs at the time he fell ill and was hospitalized. His treatment continued from 28.8.2014 to 1.11.2014. During the course of his treatment, the policy which the petitioner company had taken having expired, a renewal for another year was taken and under the renewed policy, the expenditure on treatment of the employees was covered to the extent of Rs.5 lakhs.2. The respondent company took the view that the reimbursement of the expenditure incurred on the treatment of Mr. Khalid would be covered by the policy which was applicable at the time he fell ill, i.e., 28.8.2014 and accordingly he was paid a sum of Rs.3 lakhs on 24.12.2014. The petitioner, however, was not satisfied with the payment made by the insurer and wanted the insurer to pay a sum of Rs.5 lakhs as per the renewed insurance policy which it had taken during the treatment of Mr. Khalid. The insurer having declined the request, the petitioner approached the concerned District Forum by way of a consumer complaint.3. The complaint was resisted by the respondent interalia on the ground that the petitioner / complainant was entitled only to a sum of Rs.3 lakhs. It was also stated in the written version filed by the insurer that the amount of Rs.3 lakh was disbursed in full and final settlement of the claim and the complainant having approached the District Forum in the year 2018, the complaint was barred by limitation.4. The District Forum having allowed the consumer complaint, the insurer approached the concerned State Commission by way of an appeal. Vide impugned order dated 25.1.2020, the State Commission allowed the appeal and consequently dismissed the complaint. Being aggrieved, the petitioner is before this Commission by way of this revision petition.5. The primary question involved in this petition is as to whether the reimbursement in respect of the treatment of Mr. Khalid would be governed by the policy which was in force at the time he fell ill or it would be governed by the policy which was taken by the petitioner company during the course of his treatment. In my opinion, the insurer was fully justified in taking the stand that the reimbursement in respect of the treatment for the illness which happened during the subsistence of first policy would be governed by the terms and conditions of the first policy and not by the terms and conditions of the policy which was taken after he had already fallen ill and was undergoing treatment. If the stand taken by the petitioner / complainant company is accepted, it would result in a situation where an insured who say for instance is covered to the extent of Rs.1 lakh he having paid the premium on the sum insured of Rs.1 lakh is admitted in a hospital and discovers that he is suffering from an ailment which requires an expenditure which is much more than the sum assured, he would be tempted to take another insurance policy with a view to cover the additional expenses which he is likely to incur on his treatment. Such a course, in my opinion, cannot be allowed. In a mediclaim policy, the claim is required to be settled as per the terms and conditions of the policy applicable at the time when the insured falls ill.6. In the present case, the sum insured was enhanced from Rs.3 lakhs to Rs.5 lakhs during the course of treatment on Mr. Khalid. Had the sum insured been revised downward from Rs.3 lakhs to Rs.2 lakhs, would the complainant / petitioner company still have taken the same stand i.e. that the expenditure incurred on the treatment of the employee would be covered by the renewed policy and not by the policy applicable at the time he fell ill. The obvious answer is in the negative. The rights and obligations under such an insurance policy get crystalized on the date on which the insured falls ill. Mr. Khalid having fallen ill during subsistence of the first policy and the amount payable under the first policy being restricted to Rs.3 lakhs, the petitioner company has been rightly paid that amount by the insurer.7. The payment of Rs.3 lakhs to the complainant / petitioner was made on 24.12.2014. It is difficult to accept that the petitioner company could not understand from the said payment that it was made in full and final settlement of its claim. The amount paid to the complainant was the maximum amount payable under the policy applicable at the time when Mr. Khalid fell ill. The petitioner company, therefore, could very well know that the payment of Rs.3 lakhs had been made in full and final settlement of its claim as far as the insured was concerned. Therefore, if the said amount was not acceptable to the complainant, it ought to have approached the concerned District Forum by way of a consumer complaint within two years of receiving the said amount i.e. on or before 24.12.2016. The petitioner company having approached the District Forum in the year 2018, the complaint was clearly barred by limitation prescribed in Section 24A of the C.P. Act.8. The learned counsel for the petitioner / complainant submits that the insurer having renewed the policy with a larger sum assured for its employees, during the course of the treatment of Mr. Khalid, it must necessarily reimburse the petitioner for the entire expenditure incurred on the treatment of Mr. Khalid even if the illness of Mr. Khalid is taken as a pre-existing ailment at the time when the policy was renewed. There is no evidence or any allegation of the petitioner having disclosed to the insurer at the time of seeking renewal of the policy that one of the beneficiaries of the policy was already undergoing treatment in a hospital. Therefore, it would be difficult to say that at the time was policy was issued, the insurer was aware of the existing illness of Mr. Khalid. In any case, in my opinion, the relevant date for deciding the reimbursement payable in such a case would be the date on which the insured / beneficiary falls ill unless he contracts an altogether different disease after issuance of the renewed policy. In the present case, Mr. Khalid did not contract a fresh illness after the renewed policy was issued. He was treated and the treatment continued for about 03 months for the ailment which he had contracted at the time when the first policy was still in force.9. The learned counsel for the petitioner submits that when the insured/beneficiary contracts an illness which continues beyond the date on which the first policy expires and a renewed policy is issued, he would be governed by the renewed policy since the illness is a dynamic process and an interpretation b
Please Login To View The Full Judgment!
eneficial to the same needs to be taken in such matters. I, however, find myself unable to accept the contention. In my opinion, as far as the expenditure incurred on the treatment of an illness contracted before the renewal of the policy is concerned, the parties would be governed by the policy which was in force on the date such illness is contracted. If, however, an altogether different illness is contracted by the beneficiary/insured after renewal of the policy, he will be governed by the terms and conditions of the renewed policy as far as the subsequent illness is concerned.10. For the reasons stated hereinabove, I find no ground to interfere with the order passed by the State Commission. The revision petition is, therefore, dismissed with no order as to costs.