State Consumer Disputes Redressal Commission
Cholamandlam M S Gen.Ins.Co.Ltd vs Sureshgiri Pashagiri Goswami on 31 July, 2023
Details DD MM Year
Date of Judgment 31 07 2023
Date of filing 06 08 2022
Duration 25 11 00
IN THE STATE CONSUMER DISPUTES REDRESSAL COMMISSION
STATE OF GUJARAT
COURT NO.4
Appeal No. 656 of 2022
APPLICANT: Cholamandalam Ms. General Insurance Co. Ltd.
Near ICICI Bank, Highway Road,
Tal. & Dist. Mehsana.
Notice if any to be served at:
2nd Floor, Optionz Building, 18 S P Colony,
Opp. Nest Hotel, CG Road, Ahmadabad- 380009.
V.s
RESPONDENT: Sureshgiri Pasagiri Goswami
Punasan, Tal. & Dist. Mehsana.
CORUM: Mr. R. N. Mehta, Presiding Member.
APPERANCE: Mr. R. P. Raval, Ld. Advocate for appellant.
Mr. M. T. Rangwala, Ld. Advocate for Respondent.
Order by Hon'ble Mr. R. N. MEHTA, Presiding Member.
[1]. Being aggrieved by the order & judgment dated 21.06.2022, of District Commission Mehsana in Complaint No. 192 of 2018, the original opposite party has presented this appeal and submitted that the impugned order is illegal, unjust, contrary to evidence on record and also contrary to the principles of law of contract. The Ld. District Commission, miserably failed to appreciate the provisions of the Insurance Contract and misdirected itself and awarded Rs. 1,20,216/- together with interest at the rate of 7% from the date of complain, K.Navlakha A/656/2022 Page 1 of 8 compensation for mental harassment Rs. 2,000/-, and cost of Rs. 1,000/- for the litigation.
[2]. Before the District Commission, the complainant had filed complaint alleging therein deficiency in service on the part of the present appellant in as much as the appellant insurer had repudiated the claim of insured on 08.10.2018 giving false reasons that the insured had taken treatment for the old injuries and therefore, the claim is not payable. It is stated in complaint that the complainant had taken Insurance Policy No.2868/00109290/0188/000/01 for the period from 30.09.2017 to 29.09.2018 for the sum insured of Rs. 3,00,000/-. The policy that was obtained was known as "Group Health Insurance Policy." It was stated in the complaint that none of the family member of the complaint insured had any pre-existing disease. It is also stated in the complaint that complainants wife Ms. Jignashaben had fell down on 27.08.2018 and had accidental injury at Spinal cord L5 and S1PID. She was taken to Orthoplus Hospital at Mehsana. Where she was examined by doctor who then advised for MRI which was done, examined, on that basis further treatments were recommended. She was then taken to Ahmadabad where Dr. Tarak Patel of Swarna Spin Hospital was consulted. He had advised for the surgery for which she was hospitalized from 16.09.2018 to 20.09.2018. According to the complainant, during this hospitalization, total expenses came to Rs. 1,50,000/-. All these bills and treatment papers were submitted to claim the insurance amount from the opponent. But the opponent Insurance Company repudiated the claim vide letter dated 08.10.2018. It is stated in complaint that in repudiation letter, it was stated that the insured had taken a treatment for the old injuries and medical reports shows that it was necessitated because of old disease. The complainant insured being aggrieved by the said repudiation letter, filed complaint before the District Commission.
K.Navlakha A/656/2022 Page 2 of 8[3]. The District Commission Mehsana, admitted the complaint and issued notice to the opposite party. The opponent appeared through Advocate and filed reply. It was contended in the reply that complaint as it is not maintainable, that complainant had no cause of action to file the complaint. It was specifically contended that the treatment, which was taken by the insured beneficiary, was excluded for the period of first Two years. The general exclusion clause specifically prescribes the period of Two years for such a treatment. It is specifically mentioned therein that the complainant's wife had taken a treatment of Vertebral Disk Prolapse which squarely false within the general exclusion clause and since the hospitalization was within the period of Two years the complainant is not entitle for any amount. The opponent has produced on record terms and conditions of the policy and also the Scheduled of Policy. In rejoinder the complainant has reiterated the fact stated in the original complaint and denied the facts that has been mentioned in the reply of the opponent.
[4]. The District Commission heard both the parties and observed in the judgment that it is not disputed between the parties that the first insurance policy was for the period from 30.09.2016 to 29.09.2017 and the renewal thereof was from the period of 30.09.2017 to 29.09.2018. So far sum insured is concerned, there is no dispute between the parties. It has been specifically observed in the judgment that the complainant's wife had taken the treatment which is described as under:-
"L512 S1 LAMX + MFX + LT SIDED DX"
This treatment was mentioned in the discharge summery produced by the complainant. Therefore, it is also not in dispute that the complainant has taken treatment for the Spinal cord. The date of hospitalization is also not in dispute. The District Commission has while allowing the complaint referred judgment of the Hon'ble National Commission rendered in Revision Petition No. 3552/2014 and observed that Hon'ble NCDRC, has held that merely because few days are left for completion of K.Navlakha A/656/2022 Page 3 of 8 Two years which is applicable for the exclusion terms, it cannot be a ground for denial of the legitimate claim of the complainant insured. Therefore, relying upon the bills produced by the complainant, the District Commission had awarded Rs. 1,20,216/- together with interest. The District Commission had allowed compensation for mental agony at Rs. 2,000/- and cost of Rs. 1,000/-.
[5]. Heard Mr. R. P. Raval for Appellant Insurance Company, and Mr. M. T. Rangwala for the Respondent. Mr. Raval, drawn our attention at page No. 19, which is a copy of the complaint filed by the complainant. In the said complaint, he submits that complainant has not mentioned about the first policy period. Mr. Raval submited that when the dispute is with regard to the period of exclusion clause, it was very much necessary for the complainant to mention in the complaint when the first policy was obtained. This shows the tendency of the complainant. According to Mr. Raval, the complainant has mentioned in the complaint that the expenses incurred for the treatment of Spinal cord. The complainant has deliberately alleged in the complaint that the insurance company has not disclosed terms and conditions of the policy to insured and the coverage was never informed to complainant in local language. The complainant also has alleged deficiency in service on this ground. Mr. Raval has drawn our attention to page No. 24, which is a copy of the repudiation letter the important part which is reads as under:-
"On scrutiny of the claims documents submitted, we observe that the claim is not admissible for the following reasons:
On perusal of the claim documents it is observed that the present treatment for Vertebral Disc Prolapse, which is excluded in the policy for the first two years. Hence the claim is inadmissible as per General Exclusion Clause C-2 No indemnity is available or payable for claims directly or indirectly caused by, arising out of or connected to the following Cataract, Benign Prostratic Hypertroph, K.Navlakha A/656/2022 Page 4 of 8 Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Fistula in anus, Piles, Internal Congenital disease, Sinusitis & related disorders, Gall Stone, Spondilitis, Spondilosis, Knee/Hip joint replacement, Internal Congenital disease, Osteoarthritis of any joint, Calculus disease of Gall Bladder and Urogenital, Gastric and Duodenal ulcers, Internal Tumours, cysts nodules, polyps including breast lumps (each of any kind unless malignant), Gout & Rheumatism, ENT disorders & surgery, Surgery of genito urinary system, Surgery for prolapsed inter vertebral disk, Surgery of varicose veins & varicose ulcera, surgery on tonsils. While expressing our inability to pay this claim due to the above mentioned reason, we reiterate our obligation to pay all admissible claim fairly and promptly"
Mr. Raval, also had drawn our attention at page No. 25 which is the schedule of policy for the period from 30.09.2016 to 29.09.2017. He submits that this indicates that the complainant insured had policy from 2016. However, this fact was knowingly not disclosed by the complainant. In this particular policy schedule, there is a note which reads as under:-
"This is subject to Master Policy terms and conditions issued to M/s. Dewan Housing Finance Corporation Limited.
The policy wording is available in nearest DHFL Branch In case of any change in Nominee details, you may send your communication to nearest branch of Chola MS."
Mr. Raval submits that since it is the Group Insurance policy, the Master Policy was supplied to M/s. Dewan Housing Finance Corporation Ltd. and the policy wording can be seen from the said DHFL Branch. On page No. 26 he has drawn our attention which reads as under:-
"any illness diagnosed or diagnosable within 30 days of the effective date or first health insurance policy under this policy K.Navlakha A/656/2022 Page 5 of 8 Following diseases are excluded during the first two years of inception of policy with the insurer.
Cataract, Benign-Prostratic-Hypertrophy, Hysterectomy for Menorrhgia or Fibromyoma, Hernia, Hydrocele, Fistula, Piles, Sinusitis & related disorders, Gall Stone, Spondilitis, Spondilosis, Knee/Hip joint replacement, heart disease, Internal Congenital disease, any type of Carcinoma/Sarcoma/Blood Cancer, Osteoarthritis of any joint, Calculus disease of Gall Bladder and Urogenital, Gastric and Duodenal ulcers, Internal Tumours, cysts nodules, polyps including breast lumps (each of any kind unless malignant), Gout & Rheumatism, ENT disorders & surgery, Surgery of genito urinary system, Surgery for prolapsed inter vertebral disk, Surgery of varicose veins & varicose ulcera, surgery on tonsils. Pregnancy (other than ectopic pregnancy), childbirth and their consequences, including changes in chronic conditions as a result of pregnancy."
Thus, it was very much clear from the policy condition that in case of surgery for Prolapsed Vertebral Disk, the claim is excluded for the first 2 years from the inceptions of the policy. Mr. Raval submits that it is not the case of the complainant that he had policy prior to 2016. Under such circumstances, it was not open for the complainant to put the claim before the Insurance Company within two years from the first inception date. If we considered two years from the first inception of the date with the date of hospitalization, it is clear that the claim is falling within the scope of the exclusion clause of two years. The District Commission, while allowing the complaint considered that the claim was submitted 14 days prior to the completion of the two years and therefore, it could have been ignored and benefits of the policy ought to have been given to the complainant.
K.Navlakha A/656/2022 Page 6 of 8[6]. Mr. Raval also submitted that the District Commission, has relied upon the judgment of Hon'ble NCDRC, in Revision Petition No. 3553/2014. We have gone through and considered it and of the opinion that this judgment is not applicable to facts of the present case. It has been specifically mentioned in the said judgment that complainant had policy from October 2007 whereas the treatment was taken in the year of 2011 and therefore, 2 years exclusion clause not applicable. Mr. Raval also submitted that it was also submitted before the Hon'ble National Commission by the petitioner that particular clause was not part of the policy and the respondent failed to place on record any such terms and conditions and that is why the Hon'ble National Commission had accepted the claim of the insured. It is not the case here. In the instant case the date of policy, the date of hospitalization, nature of treatment, sum insured all facts are admitted. The only thing remains that is the submission of the complainant that he was not served with the terms and conditions of the policy. Admittedly, the complainant has not disputed the Schedule of Policy supplied to him as discussed earlier. The Scheduled of Policy specifically mentions therein that the Master Policy terms and conditions are supplied to Dewan Housing Finance Corporation Ltd. So it was for the complainant to avail the copy from the Dewan Housing Finance Co. Ltd. as the policy was issued because of the loan agreement with the Dewan Housing Finance Co. Ltd. Considering all these aspects, we are of the opinion that the order passed by the District Commission requires to be modify and therefore, we passed following final order.
ORDER
[1] The appeal No. 656/2022 is hereby allowed.
K.Navlakha A/656/2022 Page 7 of 8
[2] The order of the District Commission Mehsana, dated 21.06.2022 in
Complaint No. 192/2018 is hereby quashed and set aside. The original complaint No. 192/2018 is hereby stands dismissed.
[3] There shall be no order as to cost. [4] The office is directed to supply the copy of this order to the parties free of
cost at earliest. And also supply the copy of order in PDF format to concerned District Forum by e-mail.
[5] The office is also further directed to refund the amount that has been deposited by the appellant during the presentation of appeal, together with the interest accrued thereon. And the advocate for the appellant is directed to furnish the bank details of the appellant, so as to enable the office to refund through RTGS or NEFT.
Pronounced in the open Court today on 31th July 2023.
[R. N. Mehta] Presiding Member.
K.Navlakha A/656/2022 Page 8 of 8