ORIENTAL INSURANCE CO LTD vs MADAN KUMAR DUTTA

CHALLENGE in this revision is to the order dated 28. 9. 2007 of Consumer Disputes Redressal Commission, West Bengal, Kolkata partly allowing appeal against the order dated 28. 2. 2007 of a District Forum. The District Forum had allowed the complaint with direction to the petitioner to pay amount of Rs. 15,000 by way of reimbursement of the expenses incurred on the treatment of the wife of respondent, pay Rs. 10,000 as compensation for mental agony as also cost. In appeal while affirming the Forum''s order only the amount of compensation was reduced from Rs. 10,000 to Rs. 5,000 by the State Commission.

RESPONDENT purchased a Medi-claim policy for himself and his wife for the sum of Rs. 50,000 each from the petitioner Insurance Company in the year 1998. Policy was thereafter renewed every year in April 2001, wife of the respondent fell ill and was admitted in Belleview Clinic, Calcutta where she was operated upon for Hysterectomy on 9. 5. 2001. On claim made being repudiated by the petitioner by the letter dated 12. 7. 2002, the respondent filed complaint which was contested by the petitioner. It was alleged that Policy No. 720 of 2001 under which the claim for reimbursement of mediclaim expenses was made, was renewed after a lapse of 14 days from the date of expiry of previous Policy No. 629 of 2000. Later policy had expired on 29. 10. 2000 and the former policy became operative from 13. 11. 2000. Claim made was not payable under Exception Clause 4. 3 of the policy. The controversy mainly centres around the interpretation of Clause 4. 3 which runs as follows: "4. 3 During the first year of the operation of insurance cover, the expenses on treatment of diseases 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. If these diseases (other than congenital internal disease) are pre-existing at the time of proposal they will not be covered even during subsequent period of renewal. If the insured is aware of the existence of congenital internal disease before inception of policy, the same will be treated as pre-existing. "

Bare reading of this clause would show that the claim for operation of hysterectomy, etc. is inadmissible during the first year. Further, such a claim is also not payable if the enumerated disease was pre-existing at the time of the making of proposal. It is not the case of Insurance Company that the ailment for which the wife of respondent underwent hysterectomy was existing even prior to taking of the policy in the year 1998 which has been renewed from year-to-year. Submission advanced by Mr. Maibam N. Singh, Adv. for the petitioner is that as there was break in renewal of policy No. 720 of 2001 of 14 days, this policy is thus to be treated as a new policy and claim for hysterectomy operation was, therefore, not admissible under first part of Clause 4. 3 of the policy. Since the policy was taken in the year 1998 and was renewed thereafter evey year, reference to the ''first year'' in above clause would mean the period for which the policy was initially purchased. Break of 14 days in renewal, therefore, cannot be made ground to deny the claim by invoking Clause 4. 3 in the present case. There is no illegality or jurisdictional error in the order of State Commission calling for interference in revisional jurisdiction under Section 21 (b) of the Consumer Protection Act, 1986. Accordingly, revision is dismissed. R. P. dismissed.