AI Structured Summary
Not yet generated for this judgment
Judgment
THIS revision petition has been filed by the Petitioners/OP against the impugned order dated 8.2.2008 passed by the M.P. State Consumer Disputes Redressal Commission, Bhopal (in short, ''the State Commission '') in Appeal No. 2268 of 2005 - Smt. Shobha Mukhia Vs. The Oriental Insurance Co. Ltd. by which, while allowing appeal, order of District Forum dismissing complaint was set aside.
BRIEF facts of the case are that Complainant ''s/Respondent ''s husband obtained Medi-claim policy for himself and complainant for Rs.1,00,000/- and for his son for Rs.50,000/- for a period commencing from 12.10.1999 to 11.10.2000 and further renewed it from 18.10.2000 to 17.10.2001. Later on, on the request of complainant, coverage of complainant was enhanced to Rs.3,00,000/- from Rs.1,00,000/- on the request of complainant by letter dated 22.11.2000. It was further alleged that complainant was admitted in the hospital first time on 3.8.2000 and later on was admitted in hospital from time to time and incurred expenses of Rs.4,13,992/- in the treatment. Complainant sent intimation by post to OP/petitioner regarding hospitalisation on 10.8.2000 and on subsequent dates. By letter dated 18.12.2001, complainant submitted claim, but claim was repudiated by OP vide letter dated 17.1.2002 on flimsy grounds. Complainant alleging deficiency on the part of OP filed complaint before District Forum. OP/petitioner resisted claim, filed written statement and submitted that complainant has violated terms and conditions of the insurance policy and no intimation was given regarding hospitalization within prescribed period and claim was also not preferred within 30 days of discharge. It was further alleged that complainant suppressed material facts regarding previous disease and treatment and gave untrue answers; hence, complaint be dismissed. Learned District Forum after hearing both the parties dismissed complaint. Appeal filed by the complainant was allowed by learned State Commission vide impugned order and petitioner was directed to pay Rs.2,00,000/- to the respondent against which, this revision petition has been filed. Heard learned Counsel for the parties and perused record.
LEARNED Counsel for the petitioner submitted that respondent has suppressed disease in the proposal form while obtaining first policy and has not revealed previous hospitalization, disease and treatment while obtaining second policy and further violated conditions of policy and learned District Forum has rightly dismissed complaint, even though, learned State Commission has committed error in allowing appeal; hence, revision petition be allowed and impugned order be set aside. On the other hand, learned Counsel for the respondent submitted that no conditions have been violated by respondent and there was no suppression of previous disease and in such circumstances, order passed by learned State Commission is in accordance with law which does not call for any interference; hence, revision petition be dismissed.
PERUSAL of record reveals that proposal form for the first policy was submitted and previous treatment, disease, etc. were denied by the complainant. Learned State Commission has rightly observed that no evidence was adduced by OP to show that on the date when complainant obtained first policy on 12.10.2009, she was having any such renal ailment or even symptoms so as to make her to believe that she was required to receive treatment for the said ailment. Learned State Commission further rightly observed that on 13.9.1999, hypertension was detected in the complainant and mere existence of hypertension is not sufficient to infer that complainant was also having renal ailment. Learned State Commission rightly disbelieved report of Investigator Mr. Pradeep Chhajed who is a Chartered Accountant having no expertise in the field of medical science and in such circumstances, we do not find any evidence regarding previous disease suffered by complainant. Thus, there was no suppression of previous treatment as well as disease and in such circumstances, learned State Commission rightly held that on this ground claim should not have been repudiated by OP. It is admitted case on the side of complainant that complainant was hospitalized from 3.8.2000 to 9.8.2000, from 3.9.2000 to 5.9.2000, from 12.10.2000 to 9.11.2000, from 1.1.2001 to 8.1.2001. Period of first policy was from 12.10.1999 to 11.10.2000. In such circumstances, whatever the expenses incurred by the complainant in her treatment while hospitalized in this period, she is entitled to get reimbursement upto the limit of her policy.
AS far as second policy for the period from 18.10.2000 to 17.10.2001 which was issued after a lapse of first policy, it cannot be treated as renewal of first policy because renewal has to be made before lapse of policy. Learned Counsel for the respondent submitted that this policy was issued with a cumulative bonus meaning thereby, no claim bonus was given which can be given only if policy is renewed without claim. For the sake of arguments, even if it is presumed that second policy was in pursuance to renewal of first policy, there was clear cut suppression of previous hospitalization and treatment. Though, no fresh proposal form was taken by the OP from complainant, but it was obligatory on the part of complainant to disclose previous treatment and hospitalization before applying for renewal/grant of next policy. Learned State Commission has committed error in not considering this aspect and as there was suppression of previous treatment, hospitalization and treatment of disease, in second policy for 18.10.2000 to 17.10.2001, complainant is not entitled to get any reimbursement under the second policy and OP/petitioner has not committed any error in repudiating claim under the second policy and learned State Commission has committed error in allowing reimbursement under second policy.
AS per terms and conditions of policies, complainant was under obligation to give intimation to the OP within 7 days from hospitalization. Learned Counsel for the respondent has drawn our attention towards intimation sent Under Postal Certificate (UPC), but they cannot be believed because treatment was continuing in Nadiyal (Gujarat) whereas, these intimations under UPC have been sent from Ujjain. Not only this, had these intimations been given by the complainant to OP on those dates, next policy would not have been issued by OP in favour of petitioner that too after granting no claim bonus. In such circumstances, it can be inferred that there is violation of Condition No. 5.3 regarding intimation by the complainant to OP within 7 days from hospitalization. As per Condition No. 5.4, claim was to be filed within 30 days from date of discharge from the hospital. Complainant admittedly filed claim on 18.12.2001. Under the first policy, complainant remained under hospitalization upto 5.9.2000 and remained under hospitalization under second policy upto 8.1.2001 and further was seen in the OPD of hospital on 12.10.2002. Apparently, there is violation of this condition, as claim should have been filed within 30 days from discharge from the hospital, but claim has been filed after 11 months of discharge from the hospital on 8.1.2001. Note has been appended below, Condition No. 5.4 and in extreme cases of hardships this condition can be waived by insurance company. In the present case, as complainant remained hospitalized on number of times for different period for renal ailment and kidney transplantation, we deem it proper to waive condition of intimation of hospitalisation within 7 days and filing claim within a period of 30 days and we deem it also proper to allow reimbursement of medical expenses incurred during subsistence of first policy upto the extent of coverage of Rs.1,00,000/-.
CONSEQUENTLY , revision petition filed by the petitioner against the respondent is partly allowed and impugned order dated 8.2.2008 passed by learned State Commission in Appeal No. 2268 of 2005 - Smt. Shobha Mukhia Vs. The Oriental Ins. Co. Ltd. is partly set aside and petitioner is directed to reimburse Rs.1,00,000/- incurred as expenditure on hospitalization and treatment under the first policy within 30 days from today, failing which, it shall carry interest @ 9% p.a. from 8.2.2008, the date on which, order was passed by learned State Commission till realization.