State Consumer Disputes Redressal Commission
Manager The Oriental Insurance Co.Ltd. vs Smt. Tara Kesharwani & Other on 3 July, 2013
CHHATTISGARH STATE
CONSUMER DISPUTES REDRESSAL COMMISSION,
PANDRI, RAIPUR(C.G.)
Appeal No.FA/12/496
Instituted on : 13.09.2012
Manager,
The Oriental Insurance Company Limited,
Branch Office, Itwari Bazar, Raigarh,
Through : Divisional Office No.1,
Jail Road, Kutchery Chowk,
Raipur (C.G.) ... Appellant.
Vs.
1. Smt. Tara Kesharwani, W/o Shri Kailash Kesharwani,
R/o : Kewtapara,
Raigarh (C.G.)
2. Claims Manager,
Dedicated Health Care Services,
TPD India Private Limited, Khambhata Building,
Eroj Theatre Building, East Wing, Third Floor,
42 - Maharshi Karve Marg - Mumbai - 20,
Present address : Jindal Road, Raigarh (C.G.)
3. Manager,
Dedicated Health Care Services,
TPD India Private Limited, Devendra Nagar,
Raipur (C.G.) ... Respondents.
PRESENT: -
HON'BLE SMT. VEENA MISRA, PRESIDING MEMBER
HON'BLE MISS HEENA THAKKAR, MEMBER
COUNSEL FOR THE PARTIES: -
Shri Manoj Prasad, for appellant.
Shri Prabhat Pradhan, for respondent No.1.
Respondent Nos.2 & 3 proceeded ex-parte.
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ORDER
Dated : 03/07/2013 PER: - HON'BLE SMT. VEENA MISRA, PRESIDING MEMBER This appeal is directed against the order dated 08.08.2012 passed by the District Consumer Disputes Redressal Forum, Raigarh (C.G.) (hereinafter referred to as 'District Forum' for short) in Complaint Case No.89/2011 whereby the complaint was allowed.
2. Brief facts as per averments of complaint are that the complainant had obtained mediclaim policy No.1524034820091235 for herself and her husband from OP No.3 in the year 2005 and continued to pay premium subsequently also. On 18.02.2009 the complainant was examined by gynaecologist Smt. Suchitra Tripathy and on her advice the complainant consulted Cardiologist Dr. Prakash Mishra at Ramkrishna Care Hospital, Raipur. The doctors at Ramkrishna Hospital advised her to go to Dr. Devdutta Bhattacharya at Rabindra Nath Tagore International Institute. The complainant had to spend Rs.2,88,300/- towards her treatment. The complainant had informed OPs regarding treatment and subsequently, laid claim with all necessary documents but on 16.06.2009 OP No.1 had sent 'deficiency letter' to the complainant demanding certain documents which were sent by the complainant on 18.06.2009 with copy to OP No.3. The amount was not paid to the complainant hence after serving legal notice complaint was filed.
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3. OP Nos.1 and 2 neither appeared nor filed written version. OP No.3 resisted the complaint and filed written version of denial, denying most of the averments of the complaint. It was admitted that the complainant had obtained mediclaim insurance policy for self and her husband in the year 2005. The fact of sending deficiency letter has also been admitted. From the documents given by the complainant it was not clear as from when she was hypertensive. Despite demand documents were not presented. In absence of such documents it was not possible to decide the claim. She did not give certificate of doctor as was required. It was further averred in written version that the policy was not continuous but there were several breaks during prior to renewal. Hence the would be deemed to be a new policy for coverage of treatment. On 24.02.2009 the complainant was admitted to Rabindra Nath Tagore International Institute for hypertension. As the policy was not renewed prior to expiry of the earlier policy it will be deemed to have been issued as a new policy on 21.08.2008. In terms of clause 4.1 to 4.3 of the policy the claim was not payable. Hence there was not deficiency in service by the insurer.
4. After consideration of material before it the learned District Forum had come to the conclusion that by not paying the claim the OP No.3 had committed deficiency in service and had issued necessary directions for payment.
5. Final arguments heard and record perused.
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6. Learned counsel for appellants submitted that the learned District Forum has failed to appreciate clauses 4.1 to 4.3 of the policy conditions and has wrongly found the policy to be continuous. Written version and affidavit filed by the insurer were not properly considered by the District Forum while passing the impugned order. On the aforesaid grounds learned counsel for the appellant insurer prayed for allowing the appeal, setting aside the impugned order.
7. Learned counsel for the respondent no.1 / complainant reiterated the stand taken before the District Forum. He submitted that complainant had obtained mediclaim coverage since the year 2005 and the insurer had always renewed the policy without obtaining any fresh proposal so delay or gap of a few days in renewal cannot fatal to the claim of the complainant. Learned counsel for respondent no.1 submitted that the District Forum has taken the correct view and hence there is no need of interference with the impugned order. He prayed for dismissal of appeal.
8. We perused Individual Mediclaim Policy Schedule document. This document is in two pages but we could not find any clause 4.1 to 4.3 as stated by learned counsel for appellant. The insurer has produced a separate document which is Prospectus Mediclaim and this document contains exclusions under clause 4 and its sub-clauses. There is neither any pleading nor any other material to suggest that such prospectus was ever made available to the complainant and the complainant was aware of any //5 // such exclusion. Normally grace period of 15 to 30 days is available for renewal of policy. Policy for the year 2007-2008 covered the period from 14.08.2007 to 13.08.2008 and the last policy was issued on 21.08.2008 for the period till 20.8.2009. There is only a gap of 7 days. So we believe that in case the insurer wishes that the premium is positively to be paid prior to the date when the policy is to expire, specific condition should be printed in bold letters on the policy document itself instead of being mentioned in a separate document to be kept with the insurer. Hence we believe that on account of gap of 7 days the policy issued on 21.08.2008 cannot be said to be a new policy. Had it been a new policy, the insurer must have obtained fresh proposal form but no such proposal form has been produced on record.
9. On the basis of foregoing observations we are of considered opinion that the respondent no.1/complainant was continuously purchasing mediclaim policy every year without any break and had never laid any claim prior to the claim in question. In these circumstances she was entitled get the claim. The order of the District Forum is affirmed and the appeal being devoid of any merit is hereby dismissed. The insurer is directed to pay Rs.1,000/- to the respondent no.1/ complainant towards cost of this appeal in addition to the amount payable under the order of District Forum.
(Smt.Veena Misra) (Ms. Heena Thakkar )
Presiding Member Member
/07/2013 /07/2013
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