State Consumer Disputes Redressal Commission
The New India Assurance Co. Ltd., vs Raj Rani Saluja on 29 April, 2011
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB,
S.C.O. NO. 3009-10, SECTOR 22-D, CHANDIGARH.
First Appeal No.97 of 2008
Date of institution : 6.2.2008
Date of decision :29.4.2011
The New India Assurance Co. Ltd., Regional Office, SCO 36-37, Sector 17-A,
Chandigarh through its duly constituted attorney.
.......Appellants
Versus
Raj Rani Saluja wife of Sh. Roshan Lal Saluja C/o Roshan Lal Prem Nath, Old
State Bank Building Malout, District Muktsar.
......Respondent
First Appeal against the order dated 7.12.2007 of
the District Consumer Disputes Redressal Forum,
Muktsar.
Before :-
Hon'ble Mr. Justice S.N. Aggarwal President.
Mrs. Amarpreet Sharma, Member.
Mr. B.S. Sekhon, Member.
Present :-
For the appellants : Shri D.K. Dogra, Advocate.
For the respondent : Shri R.K. Girdhar, Advocate.
JUSTICE S.N. AGGARWAL, PRESIDENT:
The version of the respondent in the complaint was that she had taken medi-claim policy from the appellants for the period from 11.8.1999 to 10.8.2002. However after some break it was again got renewed for the period from 2003- 2004, 2004-2005 and 2005-2006.
2. It was further pleaded that the respondent had suffered the breast cancer in the year 1992. She had taken medical treatment and her ailment was cured.
3. It was further pleaded that the respondent suffered from cataract in the left eye. She was operated at Delhi on 5.6.2003 and the cataract was removed. She had taken the medi-claim policy for the period from 19.6.2003 to 18.6.2004 and from 19.6.2004 to 18.6.2005 and from 19.6.2005 to 18.6.2006. Subsequently the First Appeal No.97 of 2008. 2 cataract was developed in the right eye of the respondent. She got the treatment from Grover Eye Institute, Chandigarh and incurred some expenses which were covered by this insurance policy.
4. It was further pleaded that the respondent had fallen ill. Medical investigations were carried out. It was found that she was suffering from brain tumour. The respondent got the medical treatment from Sir Ganga Ram Hospital, New Delhi and Bombay Hospital, Bombay. The matter was reported to the appellants. They had appointed Alankit Health Care Limited as investigating agency. The said agency required certain papers from the respondent about her breast cancer. These were supplied by the respondent to the investigating agency. The medi-claim related to the period from 15.3.2005 relating to cataract in the right eye and to the period from 5.8.2005 to 28.10.2005 of the brain tamour. However the claim was not paid by the appellants.
5. It was further pleaded that thereafter the respondents served the legal notice dated 27.2.2006 through her counsel and in reply she came to know that the claim was repudiated by the appellants vide letter dated 7.4.2006. Hence the complaint for insurance claim. Compensation and costs were also prayed.
6. The appellants filed the written reply. It was admitted that the respondent had taken the medi-claim policy from the appellants originally for the period from 11.8.1999 to 10.8.2000. Thereafter it was got renewed upto 10.8.2002. There was a gap of one year. Therefore the previous continuity was broken. The medi- claim policy was re-started by the respondent with effect from 19.6.2003 to 18.6.2004.
7. It was further pleaded that the claim of the respondent falls under the pre- existing exclusion under clause 4.1 of the mediclaim insurance policy. Therefore the repudiation was legal and valid. Dismissal of the complaint was prayed.
8. The respondent filed her affidavit as Ex.C-1. She also proved documents Ex.C-2 to Ex.C-36.
First Appeal No.97 of 2008. 3
9. On the other hand, the appellants filed the affidavit of P.K. Jain, Senior Divisional Manager as Ex.OP-1, the affidavit of Ajay Roy, Manager as Ex.OP-2 and the affidavit of Vivek Goyal (Regional Head) Raksha as Ex.OP-3. The appellants also proved documents Ex.OP-4 to Ex.OP-16.
10. Learned District Forum accepted the complaint with costs of Rs.1,000/- and compensation amount of Rs.5,000/- vide impugned judgment dated 7.12.2007. The appellants were directed to make the payment of Rs.1,95,286/- with interest at the rate of 10% per annum.
11. Hence the appeal.
12. The submission of the learned counsel for the appellants was that the disease of the respondent was pre-existing. Therefore it was excluded by the terms and conditions of the medi-claim policy. Hence it was prayed that the appeal be accepted and the impugned judgment dated 7.12.2007 be set aside.
13. On the other hand, the submission of the learned counsel for the respondent was that there was no merit in the present appeal and the same be dismissed.
14. Record has been perused. Submissions have been considered.
15. The version of the respondent was that she had taken medi-claim policy in the beginning for the period from 11.8.1999 to 10.8.2000. It was got renewed for the period from 11.8.2000 to 10.8.2001 and 11.8.2001 to 10.8.2002. It was not disputed by the appellants. However there was admittedly a break for one year for the period from 11.8.2002 till 19.6.2003. Therefore the previous medi-claim insurance policies have no consequence.
16. The respondent had thereafter taken the mediclaim policy for the period from 19.6.2003 to 18.6.2004. It was got renewed subsequently for the period from 19.6.2004 to 18.6.2005 and 19.6.2005 to 18.6.2006. Copies of these insurance policies have not been placed on the file either by the appellants or by the respondents.
17. But the admitted fact is that the mediclaim insurance policy was limited to Rs.1,25,000/-.
First Appeal No.97 of 2008. 4
18. The respondent has proved the medical bills Ex.C-3 to Ex.C-34 including investigation reports but since the mediclaim policy was only for Rs.1,25,000/-, therefore, the respondent was not entitled to any amount over and above the amount of the medi-claim insurance even if she had spent more amount than this.
19. The submission of the learned counsel for the appellants was that the respondent had suffered the breast cancer in the year 1992. She was also operated for the cataract in the left eye on 5.6.2003. Therefore the disease of the respondent was pre-existing and it was excluded by clause 4.1 of the terms and conditions of the mediclaim insurance policy Ex.OP-4. Clause 4.0 and 4.1 of the mediclaim insurance policy read as under:-
"4.0 The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of:-
4.1 All diseases/injuries which are pre-existing when the cover incepts for the first time."
20. If the respondent had been taking the medical treatment for the disease which was pre-existing then of course exclusion clause 4.1 of the terms and conditions of the mediclaim insurance policy will apply but if the disease for which medical treatment has been taken by the insured, it was not pre-existing then clause 4.1 of the mediclaim insurance policy will not apply.
21. In the present case, the respondent had taken the medical treatment for the cataract in the right eye and for brain tumour. There is no evidence if the disease of cataract in the right eye and the brain tumour were pre-existing i.e. prior to the taking of the mediclaim insurance policy with effect from 19.6.2003.
22. Even if the respondent had breast cancer in the year 1992 and she had taken medical treatment for that, it does not affect the medical claim of the respondent for another disease. Similarly even if she had got medical treatment for cataract in the left eye on 5.6.2003 that will not debar the respondent from claiming the reimbursement of the amount spent by her on her medical treatment for another First Appeal No.97 of 2008. 5 disease. Therefore the claim of the respondent is not excluded by clause 4.1 of the terms and conditions of the mediclaim insurance policy.
23. However, as discussed above, the claim of the respondent cannot be over and above Rs.1,25,000/- which was the amount of the medi-claim insurance policy.
24. Learned District Forum has awarded compensation amount of Rs.5,000/-. The interest has also been awarded at the rate of 10% per annum.
25. The submission of the learned counsel for the appellants was that if the respondent has been awarded interest then she was not entitled to the compensation amount of Rs.5,000/- separately. It was also submitted that the rate of interest awarded by the learned District Forum was also on the higher side. It was prayed that the interest and compensation awarded by the learned District Forum be set aside.
26. We find merit in the submission of the learned counsel for the respondent that compensation cannot be awarded separately if the respondent is being paid interest on the amount of insurance claim. Similarly the rate of interest awarded by the learned District Forum is on the higher side.
27. Therefore the amount of compensation of Rs.5,000/- is set aside while the rate of interest is reduced to 8% per annum from the date of the complaint till the date of payment.
28. In view of the discussion held above, this appeal is partly accepted and the respondent is awarded medi-claim for an amount of Rs.1,25,000/- with interest at the rate of 8% per annum from the date of filing of the complaint till the date of payment with costs of Rs.1,000/-.
29. The appellants had deposited an amount of Rs.25,000/- with this Commission at the time of filing of the appeal on 6.2.2008. This amount of Rs.25,000/- with interest accrued thereon, if any, be remitted by the registry to the respondent by way of a crossed cheque/demand draft after the expiry of 45 days under intimation to the learned District Forum and to the appellants. First Appeal No.97 of 2008. 6
30. The interest on the amount of Rs.25,000/- shall stop running with effect from the date the appellants had deposited the same in this Commission. Interest on this amount of Rs.25,000/- shall be what has accrued on this amount when it remained deposited by this Commission in the Bank.
31. Remaining amount shall be paid by the appellants to the respondent immediately.
32. The arguments in this case were heard on 21.4.2011 and the order was reserved. Now, the order be communicated to the parties.
33. The appeal could not be decided within the statutory period due to heavy pendency of court cases.
(JUSTICE S.N. AGGARWAL)
PRESIDENT
(MRS. AMARPREET SHARMA)
MEMBER
April 29 , 2011 (BALDEV SINGH SEKHON)
Bansal MEMBER