w w w . L a w y e r S e r v i c e s . i n

The Branch Manager, M/s Oriental Insurance Company Ltd., Kodungallur v/s M.M. Jose

Company & Directors' Information:- THE ORIENTAL INSURANCE COMPANY LIMITED [Active] CIN = U66010DL1947GOI007158

Company & Directors' Information:- THE ORIENTAL COMPANY LIMITED [Active] CIN = U67120WB1935PLC094079

Company & Directors' Information:- ORIENTAL COMPANY LIMITED [Not available for efiling] CIN = U70101RJ1935ULL000047

Company & Directors' Information:- ORIENTAL INDIA LTD [Strike Off] CIN = U51226WB1983PLC036505

Company & Directors' Information:- N J JOSE AND CO PVT LTD [Strike Off] CIN = U55101KL1979PTC003037

Company & Directors' Information:- ORIENTAL CORPN PVT LTD [Active] CIN = U51909GJ1937PTC000133

Company & Directors' Information:- ORIENTAL CORPORATION LIMITED [Not available for efiling] CIN = U99999MH1937PTC002741

    First Appeal No. 274 of 2016

    Decided On, 06 August 2020

    At, Kerala State Consumer Disputes Redressal Commission Thiruvananthapuram

    By, MEMBER
    By, MEMBER

    For the Appellant: Varkala B. Ravikumar, Advocate. For the Respondent: ------

Judgment Text

A. Beena Kumari, Member

The appellant is the opposite party in C.C. No. 79/2012 on the file of Consumer Disputes Redressal Forum, Thrissur (hereinafter referred to as the District Forum for short) and the respondent is the complainant.

2. The case of the complainant is that he had taken a medi-claim family package policy from the opposite party from 2001 onwards. He used to renew that policy till this date. As per that policy if the complainant or his family members are treated as inpatient for more than 24 hours in any hospital the treatment expenses will be reimbursed by the opposite party. The complainant was admitted at Ernakulam Lissie hospital for the treatment of removing stones from kidney. He has undergone treatments on five occasions in between 13.09.2010 to 29.12.2010. Total 23 days he was treated as inpatient and he has also incurred an amount of Rs.50,000/- for the treatment. A claim was submitted with all supporting treatment records. But the opposite party denied and repudiated the claim, by stating that the policy has not completed 2 years, hence excluded as per 4.3 of the policy condition. The rejection of the claim is illegal which amounts to deficiency in service on the part of the opposite party. Hence this complaint is filed for getting the treatment expenses with compensation.

3. Notice was served on the opposite party, they entered appearance through counsel and filed detailed version. The opposite party has admitted that a medi-claim policy was issued in the name of the complainant for the period from 11.08.2010 to 10.08.2011. But the opposite party has denied all other allegations stated in the complaint against them. It is also admitted by the opposite party that the complainant has preferred five claims for different periods of hospitalization for the treatment of same disease. The claims were verified by the third party administrator and reported that all the treatments were pertaining for calculus disease, which is excluded from the scope of the policy for the first 2 years as per clause 4.3 of the policy. The opposite party has stated the details of the policies issued by them to the complainant. According to the opposite party there were breaks between the periods of policies. Therefore, the policies cannot be considered as continuous policy. Hence the policies were treated as fresh policies. The opposite party specifically denies that the complainant was a policy holder continuously, for the last 12 years. According to the opposite party they have not committed any deficiency in service or unfair trade practice towards the complainant and prayed for dismissal of the complaint with costs.

4. Both parties filed proof affidavits before the District Forum and produced documents. Complainant has produced 6 documents which were marked as Exts. P1 to P6. Opposite party produced 8 documents which were marked as Exts. R1 to R8.

5. On the basis of the entire evidence the finding of the District Forum was that the complainant being a medi-claim insurance policy holder is entitled to get the medical expenses incurred for his treatment from the opposite party. But the opposite party has denied the claim without any genuine reason and cause. The contention raised by the opposite party was that there was no continuation of the policy. Hence the claim submitted by the complainant is excluded as per clause 4.1, 4.2 and 4.3 of the policy.

6. The District Forum thoroughly examined Ext. R1 series and found that the latest policy among Ext. R1 bears previous policy No. 828. The period of that policy was 11.08.2010 to 10.08.2011. Previous policy was for the period 11.08.2009 to 10.08.2010. That policy bears policy No. 828 and previous policy number shown as 567. Another policy was for the period 10/07/2008 to 09.07.2009 which bears policy No. 567, whereas no previous policy number is stated. Hence the Forum found that the latest policy No. 938 is a continuation of policy No. 567. Since the policies are continuation of that policy, the previous policy numbers are specifically mentioned in those policies. That means the policy can be considered as effective from 10.07.2008 to 10.08.2011. The opposite party has considered the policy valid from 11.08.2009 only instead of considering 10.07.2008. For that reason the opposite party repudiated the claim as per exemption clause 4.1 to 4.3. The continuity of the renewal of the policies was maintained with the same company. Therefore the District Forum found that the complainant is entitled to get the policy benefits.

7. The claim of the complainant was for getting Rs. 50,000/- for treatment expense. But there was no supporting evidence for that claim. Ext. R6 is for an amount of Rs. 9,000/- and Ext. R8 is for an amount of Rs. 8,000/-. Hence the District Forum allowed to realize Rs. 17,000/- from the opposite party with 9% interest from the date of complaint till realization. Against this order the opposite party has filed this appeal.

8. The counsel for the appellant vehemently argued that the District Forum failed to consider the contention of the appellant/opposite party that the policy No. 828 dated 11.08.2009 is not a renewed policy of the previous policy No. 567 dated 10.07.2008 which expired on 09.07.2008 and there was a break of 32 days in between the two policies. Hence policy No. 828 is a new policy and exclusion period is to be reckoned from the date of policy No. 828 dated 11.08.2009 and so the disease for which the complainant was treated is excluded as per condition No. 4.3 of the policy and hence the complainant is not entitled to claim the treatment expense from the appellant.

9. The District Forum found that if the opposite party has considered the policies as separate and fresh policies, separate proposal forms would have been signed and submitted by the complainant and that was not seen produced by the appellant/opposite party. That itself shows that those policies were continuous policies and only for denying the claim, the opposite party has raised an objection by stating that there was break in renewal of the policies. The opposite party has not produce

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d any contra evidence against that argument raised by the complainant. For that reason the District Forum accepted the claim of the complainant that the policy was a continuous policy for more than two years and found that there was deficiency in service from the side of the appellant/opposite party. For that reason the District Forum allowed the complaint. From the above mentioned discussions we also find that the order passed by the District Forum is genuine and reasonable. Hence there is no need to set aside the order. In the result, this appeal is dismissed and the order passed by the District Forum in C.C. No. 79/2012 is confirmed. No order as to costs.