Oriental Insurance Co. Ltd. vs NAYANABEN MANUBHAI

BOTH these appeals arise from order dated 1st February, 2003 rendered by the learned Rajkot District Consumer Disputes Redressal Forum in Complaint No. 282/1998 directing the opponent Insurance Company to pay to the complainants Rs. 44,873.63 with interest @ 12% p.a. from 6.8.1998 till payment and cost quantified at Rs. 500/-.

WE have heard the learned Advocates for the parties. The claim which was presented before the learned Forum relates to mediclaim policy for the period from 29.4.1997 to 28.4.1998 issued on 1.5.1997 for the sum of Rs. 1,00,000/- covering complainant''s unmarried son Hemal. It is not in dispute that Hemal had already policy of mediclaim, the last one being for Rs. 30,000/- for the period from 25.10.1996 to 24.10.1997. It is also not in dispute that Hemal was suffering from Cancer and he had availed of mediclaim insurance under last mentioned policy which was in force from 25.10.1996 to 24.10.1997. However, inspite of the fact that the said policy for Rs. 30,000/- was in force he proposed fresh insurance of Rs. 1,00,000/- as per the policy of insurance in question and presented claim before the opponent Insurance Company with bills which were upto the month of July, 1997. The bills also would show that they were during the currency of the period of the earlier policy of insurance of Rs. 30,000/-. In the background of these facts what the learned Forum has observed is that the deceased insured was not required to state the material fact regarding his ailment. Hence, when he replied the particular column saying it was not applicable to the proposal for insurance of Rs. 1,00,000/- there was no question of suppression of material facts. According to the learned Forum opponent Insurance Company did know about the existence of ailment of cancer from which the insured suffered. Under such circumstances the defence of the opponent Insurance Company that the deceased insured suppressed material facts was not to be acceptable. As per the facts and circumstances of the case as noted herein above, the learned Forum is not right in making the aforesaid observations and coming to the conclusion that the complainants were entitled to the claim. The matter could have been disposed of by making a reference to a very important clause in the policy of insurance in question which says- "4. Exclusions 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. Such diseases which have been in existence at the time of proposing this insurance....."

It has been submitted on behalf of the complainants that when there was already a policy of mediclaim in existence the complainants would be entitled to mediclaim for the existing disease also. In our considered opinion this submission cannot be accepted as the policy of insurance in question was for Rs. 1,00,000/- and not for Rs. 30,000/- and it was taken during the currency of the earlier policy for Rs. 30,000/- which was in existence. Thus the policy of Rs. 1,00,000/- could, by no stretch of imagination be said to be a renewal policy.

BEARING in mind the facts of the case and in view of what is stated above, the appeal of the opponent Insurance Company is required to be allowed and the appeal of the complainants for enhancement of the claim is required to be dismissed. Following order is, therefore, passed: Impugned order dated 1st February, 2003 rendered by the learned Rajkot District Consumer Disputes Redressal Forum in Complaint No. 282/1998 is hereby set aside. Complaint bearing No. 282/1998 is hereby dismissed. Appeal No. 840/2003 is hereby accordingly allowed and Appeal No. 839/2003 filed by the complainants is hereby dismissed. We, however, do not propose to award any order of cost. Opponent Insurance Company is stated to have deposited Rs. 25,000/ in this Commission. Office is to verify that amount and pay back the same with interest, if any, to the opponent Insurance Company (appellant in Appeal No. 840/2003) by A/c payee cheque. Ordered accordingly.