Oriental Insurance directed to pay compensation in mediclaim - India Consumer Forum

Oriental Insurance directed to pay compensation in mediclaim


REVISION PETITION NO. 2745 OF 2003 (From the order dated 03.06.2003 in Appeal No. 169/03 of the State Commission, Jharkhand)

New Delhi – 110001

Smt. Parkash Devi ……..Respondent

Order Dated the 26th March, 2008 (excerpts only)

The complainant Smt. Parkash Devi took a mediclaim policy on 2.12.1997 by paying a premium of Rs. 1,554/- for a period of one year. Subsequently, her husband Bhagwan Das Agarwal and she jointly took a policy for one year (13.4.99 to 12.4.2000), which was renewed on 7.6.2000 with validity up to 6.6.2001. During the currency of this policy, Smt. Parkash Devi underwent an operation of the hernia. The claim filed was repudiated by the Oriental Insurance Company stating that under exclusion clause 4.3 during the first year of the operation of insurance cover the expenses on surgeries such as cataract, benign prosthetic hypertrophy, hysterectomy for menorrohia or fibryoma, hernia, hydrocele, congenital internal diseases, fistula in anus, piles and related disorders are excluded. The Insurance Company also contended that there was a gap of 55 days in renewing the mediclaim policy hence, it can only be construed as a fresh policy. Therefore, the exclusion clause applied to the mediclaim. Unhappy with the decision of the Insurance Company, a complaint was filed by the complainant before (respondent here) the District Forum, Ranchi.

The District Forum held that since the year of surgery was not the first year of the mediclaim policy of the complainant, she was entitled to the claim amount. The Insurer should not repudiate a claim mechanically and in a routine manner. The District Forum also held that such a view was supported by a decision of the Hon’ble Supreme Court “AIR 2001 page 549”. Accordingly, the District Forum directed the Insurance Company to pay (Rs. 6,257/- + Rs.1,379/-) i.e., Rs.7,636/- incurred by the complainant on her treatment during hospitalization.

Aggrieved by the order of the District Forum the Insurance Company filed an appeal before the Jharkhand State Commission, Ranchi. The State Commission, after hearing the parties, concurred with the decision of the Forum.

Dissatisfied with the order of the State Commission, the Insurance Company has filed this revision petition.

The main limb of the argument adduced by the Ld. Counsel for the petitioner is that there was a gap of 55 days between the expiry of the first mediclaim policy and issue of the fresh policy. The Insurance Company can condone 15 days delay only, not 55 days. Hence, the orders of the lower fora are erroneous as the policy issued on 17.6.2000 was a fresh policy. The exclusion clause is very much applicable.

As against this, the Ld. Counsel for the respondent showed us the mediclaim policy issued on 7.6.2000. In this, the Insurance Company has clearly mentioned previous year and policy No. as 2000 and 407. It has also mentioned that there is a family discount of Rs.255.50/-. He drew our attention to the prospectus issued by the Insurance Company under the Mediclaim – Hospitalization and Domiciliary – Hospitalization Benefit Policy wherein under the salient features of the policy, clause 1.3 reads as follows:

This insurance scheme also provides for :-
a) Family discount in premium (refer item 6)
b) Cumulative Bonus (refer item 9)
c) Cost of Health Check-up (refer item 10)
N.B. Renewal of insurance without break is essential. (emphasis supplied)

It is a very clear-cut condition that family discount in premium will be given, provided there is a renewal of insurance policy without break. In this case, family discount in premium has been given because the Insurance Company acknowledged the fact of renewal of the insurance policy without break, i.e., having condoned the delay. Moreover, similar family discount was also given when the policy was renewed during the previous year but when the policy was taken for the first time, such discount was not given.

We have gone through the records and heard the arguments of both the counsel. The fact is that in the policy schedule which covered the mediclaim of Bhagwan Das Agarwal and Smt.Prakash Devi, there is clear mention of family discount which, according to the prospectus issued by the Company, is allowed only in cases of renewal of insurance policy without break. The only exclusion mentioned in the policy is as follows:

It is further declared and agreed that :- This policy specifically excludes any expense incurred towards treatment of AIDS Positive/AIDS cases
As the mediclaim in this case was not for treatment of AIDS the Insurance Company could not have repudiated the claim legally.
The Commission ordered that wherever the policy conditions are not clear and capable of more than one interpretation, the interpretation which is beneficial to the consumer should be adopted. Accordingly, the revision is dismissed. The Insurance Company is directed to pay Rs.25,000/- as cost as the complainant was unnecessarily dragged to all the three consumer fora to get legitimate benefits under the policy.

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