New India Assurance Co. Ltd. vs RAJENDRA SINGH BAJAJ

THE two appeals arise out of the common order dated 31.12.2002 passed in Complaint Case Nos. 36/2002 and 57/2002 by the District Consumer Disputes Redressal Forum, Chhindwara (for short the "District Forum") whereby the complaint for deficiency in service in not making the payment of the claim under the Medi Claim Hospitalisation and Domiciliary Hospitalisation Benefit Policy, was allowed in relation to Complaint Case No. 36/2002 with an order to pay the amount of Rs. 81,130/- with interest theron at the rate of 9 per cent per annum from May, 2001 to 10.3.2002 and in Complaint Case No. 57/2002 Rs. 1,00,000/- with interest thereon at the rate of 9 per cent per annum from October, 2001 till payment, after adustment of the amount of Rs. 1,00,000/- already paid on 11.3.2002 alongwith Rs. 1,000/- as costs of the proceedings.

BRIEF facts are thus : Admittedly, the respondent obtained a Medi Claim Hospitalisation and Domiciliary Hospitalisation Benefit Policy No. 4845050208376 for the period from 5.8.2000, under which the claim is made in Complaint Case No. 36/2002 and after expiry of the said policy, another policy No. 4845050210251 for the period from 5.8.2001 to 4.8.2002, of which claim is in Complaint Case No. 57/2002. On suffernce of chest pain on 22.4.2001 the respondent was admitted in Jain Heart Clinic where after thorough examination Dr. U.C. Jain referred the respondent to Dr. Mahurkar of Nagpur. Dr. Mahurkar advised the respondent for pace maker. On the advice of Dr. Mahurkar, the respondent was admitted in the Avanti Institute of Cardiology at Nagpur on 22.4.2001 for implantation of pacemaker from where he was discharged on 28.4.2001 after permanent pacemaker implanation. The respondent claimed an amount of Rs. 85,000/- which was not paid. However, the respondent did not get relief, therefore, he went to Escorts Heart Institute & Research Centre on 23.8.2001, where he was admitted in the Hospital. After his thorough examination and treatment it was found that the pacemaker was not working properly, hence, he was advised to have another pacemaker implanted. After operation and implantation of the new pacemaker, he was, discharged on 4.9.2001 in which an amount of Rs. 1,05,000/- for operation and the expenses in administering treatment of Rs. 1,03,850/- in all Rs. 2,08,850/- were incurred. The Insurance Company treated the first claim under insurance of the first policy and second claim being continuation of the previous disease and offered the amount of Rs. 1 lac. The respondent accepted the amount under protest and filed two separate complaints. The complaints were resisted. The District Forum held that the Insurance Company erred in not making the payment as the exclusion Clause 4.2 of the Exclusions has no application, as the claim falls under condition No. 3 of the policy. The question for our consideration is whether the second claim was in continuation of the disease of the first claim or was payable as a fresh claim. It would be appropriate to quote relevant condition No. 3 and Exclusion Clauses 4.2 and 4.3 of the policy, which are as under : "3.0 ANY ONE ILLNESS Any one illness will be deemed to mean continuous period of illness and includes relapse within 45 days from the date of last consultation with the Hospital/Nursing Home where treatment may have been taken. Occurrence of same illness after a lapse of 45 days as stated above will be considered as fresh illness for the purpose of this policy.

Exclusions : 4.0....... 4.1....... 4.2. Any diseases other than those stated in Clause 4.3 contracted by the Insured Person during the first 30 days from the commencement date of the policy. This exclusion shall not however, apply if in the opinion of Panel of Medical Practitioners constituted by the Company for the purpose, the insured person could not have known of the existence of the disease or any symptoms or complaints thereof at the time of making the proposal for insurance of the Company. This condition 4.2 shall not however apply in case of the insured person having been covered under this scheme or group insurance scheme with any of the Indian Insurance Companies for a continuous period of preceding 12 months without any break. 4.3. During the first year of the operation of insurance cover, the expenses on treatment of disease such as cataract. Benign Prostatic Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal diseases, Fistula in anus, piles, Sinusitis and related disorders are not payable." 4. From the material on record, it is evident that the first pacemaker was implanted on 22.4.2001 as is evident from the Discharge Summary of Avanti Institute of Cardiology, Ex. R/5, while the second pacemaker was implanted in Escorts Heart Institute & Research Centre on 1.9.2001 which is evident from the Discharge Summary of Escorts Heart Institute & Research Centre. The period between the two is of more than 45 days, from the first implantation at Nagpur, 45 days expired on 6.6.2001, while the second implantation was done on 1.9.2001. In such circumstances, the second implantion will be treated as a fresh illness and not a continuous illness after lapse of 45 days, hence in view of condition No. 3 of the policy it would be a fresh illness.

THE contention of the Insurance Company that the claim falls in Clause 4.2 of the Exclusions cannot be accepted as in our opinion, Clause 4.2 is not applicable in the facts of this case. THE disease does not fall in Clause 4.3 nor it was a disease suffered by the respondent within 30 days from the commencement date of the policy. THErefore, Exclusion Clause No. 4.2 shall not apply besides, the respondent was covered under the scheme for a continuous period of preceding 12 months without any break. In such circumstances, in our opinion, the Insurance Company was not justified in treating the illness as the continuous one. In view of the above, the respondent was entitled to the amount of claim of Rs. 85,000/- as claimed under the first policy and in another policy to the extent of Rs. 1,00,000/- after adjustment of the excess amount paid of Rs. 15,000/-. In view of this the Insurance Company is ordered to pay a sum of Rs. 85,000/- with interest thereon at the rate of 9 per cent per annum from 11.3.2002 till payment and Rs. 1,000/- as costs of the proceedings, within a period of two months from the date of receipt of certified copy of this order, failing which the amount shall carry interest at the rate of 12 per cent per annum.

ACCORDINGLY, the appeals are partly allowed. The common order of the District Forum shall stand substituted as indicated hereinabove. A copy of this order be conveyed to the parties and a copy be sent to the District Forum along with the record of the case. Appeals partly allowed.