M.J. Mehta, Judicial Member
1. Being aggrieved and dissatisfied with the judgment and Order passed by the learned District Forum, Ahmedabad (Rural) in New Complaint No. 333 of 2012 (Old Complaint No. 266 of 2012, dated 2.5.2013 by which the complaint was dismissed the appellants/complainants have filed present appeal against the respondent/original opponents. The parties will be referred to as per their original nomenclature for the sake convenience.
2. To dispose of this appeal, few relevant facts are required to be mentioned : It is the case of the complainant that he has been taking the insurance policy since 2006. The complainant had taken the insurance policy from Winner Benefit Insurance Benefits Limited for the year 2006-2007. He has been renewing the said policy from time to time and lastly he had renewed the said policy for the year 2009-2010. It is further case of the complainant that he had taken the medi-claim insurance policy from the opponent No. 2 through Trishur Health Trust and he was a Member. That policy was for the period of 2010-2011. Policy Number was 124500/48/2011/3366. Said policy was effective from 31.5.2010 to 30.5.2011. Under the said policy the insured amount was Rs. 1,00,000. It is the further case of the complainant that during the effective period of policy, the complainant No. 2 was admitted in Gurukrupa Hospital from 20.3.2011 to 27.3.2011 for the Kidney disease. The complainant had incurred expenses of Rs. 20,498. Therefore, the complainant was admitted in the hospital from 8.4.2011 to 10.4.2011 in T.R. Memorial Hospital and he incurred expenses of Rs. 35,630. The complainants lodged claim before the learned District Forum with all required documents. The Insurance Company has repudiated the first claim on 8.6.2011 and second claim on 11.11.2011. Being aggrieved by the said repudiation, the complainants are constrained to file the aforesaid complaint before the learned District Forum.
3. After hearing the learned Advocates for both sides and considering the document and evidence produced on record, the learned District Forum was pleased to dismissed the complaint of the complainant.
4. Being aggrieved and dissatisfied with the order of the learned District Forum, present appeal is filed by the appellant /original complainants challenging the order of the learned District Forum before the State Commission.
5. Heard the learned Advocate Mr. Mohit Patel for the complainants and Mr. Dwivedi for the opponents.
6. Learned Advocate Mr. Patel has argued that the order of the learned District Forum is not just, legal, perverse and in consonance with the law. The learned District Forum has appreciated and considered the documents and evidence adduced on record. The order is bad in law and it requires to be quashed and set aside.
7. Learned Advocate Mr. Patel has further argued that the insurance policy in question was continued policy. It was in existence from 2006 vide page No. 52 Condition No. 4.3 wherein a disease of Kidney is not included, so the policy is in existence from 21.5.2009 vide page No. 33. Page Nos. 21 to 26 refer the fact of continuation of the policy. Said policy number is 124500/48/2011/3366 for the period from 31.5.2010 to 30.5.2011 and the insured amount under the said policy was Rs. 1 lakh. It was in existence. The complainant No. 2 was admitted in the hospital from 20.3.2011 to 27.3.2011 and incurred medical expenses of Rs. 20,498 . Again from 8.4.2011 to 10.4.2011 the complainant No. 2 was admitted in T.R. Memorial Hospital and incurred medical expenses of Rs. 35,630. Both the claims of the claimant were repudiated by a letter dated 8.6.2011 and 11.11.2011 under Clause 4.3. As per learned Advocate Mr. Patel the policy was renewed from time to time and it was continued policy. So, L.A. for the complainant has prayed to allow the appeal and award Rs. 56,128 the complainants with costs and interest.
8. Learned Advocate Mr Dwivedi for the opponents has argued that the order of the learned District Forum is legal, just and in accordance with law and it should be confirmed. Learned Advocate Mr. Dwidevi for the opponents argued that the insurance policy in question is not continued if their Insurance Company. The policy in question was purchased from Winner Insurance Benefits Ltd and it was a new policy. Therefore the claim was repudiated. Therefore, repudiation of the claim is correct, legal and in accordance with law and therefore, the appeal is not tenable and it requires to be rejected with costs.
9. We have gone through the record and documents produced on record and the impugned order of the learned District Forum. On going through the papers, if we consider page 52, condition 4.3, it does not exclude the kidney disease. Here in this case, the claim was rejected mainly on the ground that it was a new policy. But, as we have discussed above, it is a continuous policy. So, repudiation of claim on the ground of new policy is not tenable in the eye of law. Moreover, page No. 52 clearly discloses that kidney disease is not included in the list for which the policy does not cover the risk of the disease. Here, there is no question of pre-existing disease as it is a continuous policy. Moreover, we refer page No. 26 wherein it is included Medi Claim Family Floated cover including pre-existing disease with sub limits. If we consider that name of the claimant is included. So, that policy covers the risk of Rs. 1 lakh. Here in this case, only Rs,. 56,128 is claimed. Considering the facts and circumstances of the case, we would like to award Rs. 35,000 on lump sum basis.
10. In view of the aforesaid discussion, following order is passed.
(i) Appeal No. 1382 of 2013 is partly allowed.
(ii) The order dated 2.5.2013 passed by the learned District Forum, Ahmedabad (Rural) in New complaint No. 333 of 2012 (Old Compla
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int No. 266 of 2012) is quashed and set aside. (iii) The opponent Insurance Company is hereby ordered and directed to pay Rs. 35,000 (Rupees Thirty five thousand only) on lump sum basis with interest at the rate of 7 p.a. from the date of filing of the complaint till its realization. (iv) The opponent Insurance Company is ordered and directed to pay Rs. 5,000 to the complainant towards costs of this litigation. (v) The amount of the Award should be paid to the complainant within 60 days from the date of this order. (vi) Copy of the judgment be provided to the parties free of charge. Appeal partly allowed.