Date of Filing:17.11.2008 Date of Order:05.03.2009 BEFORE THE II ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM SESHADRIPURAM BANGALORE-20 Dated: 5TH DAY OF MARCH 2009 PRESENT Sri S.S. NAGARALE, B.A, LL.B. (SPL.), President. Smt. D. LEELAVATHI, M.A.LL.B, Member. Sri BALAKRISHNA. V. MASALI, B.A, LL.B. (SPL.), Member. COMPLAINT NO: 2465 OF 2008 T.L.N. Murthy, S/o Late T.L. Narayana Rao, 462/40, 8th Cross, Mahalakshmi Layout, Bangalore 560 086. Complainant V/S National Insurance Company Limited, Division-IV, Bangalore, No. 16, 2nd Floor, Kumara Krupa Road, Near Shivananda Circle, Bangalore 560 001. Opposite Party
ORDER By the President Sri. S.S. Nagarale The complainant submits that having received unjustified response from opposite party company against his claim for reimbursement of medical expenses incurred by him against his medical policy. Complainant submitted that he had first heart problem on 9th May-2000 at Bangalore and underwent treatment at Wockhardt Hospital in Bangalore. He took medical policy from opposite party for himself and his wife. While applying for the first policy he has declared his heart problem as preexisting and accordingly heart disease was excluded for any claim. He has continued his policy with the opposite party company without any break from 2002-03 to 2008-09. Complainant has furnished policy numbers and effective dates of policies in his complaint in para-3 of the complaint. On 29/02/2008 he had heart problem during his visit to BHEL, Tiruchirapalli, Tamil Nadu. On 06/03/2008 he returned to Bangalore and admitted to Wockhardt Hospital and Health Institute for further treatment. He was attended by Dr. P. Ranganath Nayak, Cardiologist. On 07/03/2008 there was operation and he was discharged on 09/03/2008. The exclusion clause for pre-existing disease had been revised and the policy holders having a non claim continuous policy for 4 years can put up their claim for settlement. The complainant submitted claim application on 17/03/2008. After repeated follow up, company declined to entertain the claim on the plea that the occurrence of disease was during the tenure of the previous year mediclaim policy.
The rejection of the claim by the company amounts to deficiency in service. The opposite party company bound to pay charges incurred by him. The beneficial amended rules is to be considered liberally in favour of the beneficiary since new rules covering pre-existing disease came in to effect from 01/04/2007 during the tenure of complainant’s policy. Therefore, he is entitled to claim the benefits or the expenses incurred or reimbursement. Complainant prayed that he may be compensated to the tune of Rs.2,22,805/- towards the cost incurred for undergoing treatment to the mental agony, harassment etc.,.
2. Notice issued to opposite party. Opposite party put in appearance through Advocate and defence version filed stating that the opposite party company had issued policies to the complainant from 23/03/2002 to 22/03/2003 and the same was renewed from time to time till 22/03/2009. The complainant had obtained mediclaim policy declaring in the proposal form that he was suffering from heart ailment. All pre-exiting diseases are excluded under the policy. Hence, the opposite party is not liable. Therefore, claim is repudiated. The opposite party submitted that new rules came into force on 01/04/2007. Accordingly, all the pre-existing diseases are covered only after expiry of 4th year policy which was taken continuously from the National Insurance Company. It is submitted that this rule is prospective and not retrospective. Hence, does not fall under the new rules. The opposite party requested to dismiss the complaint.
3. Affidavit evidences are filed. Arguments are heard.
4. The point for consideration is:- “Whether the opposite party is justified in repudiating the claim of the complainant?”
5. It is an admitted case of the parties that, the opposite party company had issued hospitalisation and domiciliary hospitalisation benefit policy to the complainant right from 2002-2003 to 2008-09 continuously without any break. The complainant has totally obtained 7 policies and he has given policy numbers and effective date of all the policies in his complaint. The complainant got renewed his policies from time to time till 22/03/2009. It is the case of the complainant that he was admitted to Wockhardt Hospital and Health Institute, Bannerghatta Road, Bangalore. He was attended by Dr. Ranganath Nayak, Cardiologist and he underwent operation on 07/03/2008 and discharged from the Hospital on 09/03/2008. It is the case of the complainant that the exclusion clause for pre-existing diseases hitherto existing, had been revised and the policy holders having a non claim continuous policy for 4 years and above can put up their claim for settlement. The new clause 4.1 was made applicable and effective from 01/04/2007. Under this clause all diseases/injuries which are pre-existing when the cover incepts for the first time however those diseases will be covered after continuous claim pre policy years. For the purpose of applying this condition the period of cover under mediclaim policy taken from National Insurance Company only will be considered. Based on the amendment to the exclusion clause for claim settlement the complainant submitted his application on 17/04/2008. The opposite party declined to entertain the claim on the plea that the occurrence of diseases was during the tenure of the previous year’s mediclaim policy. The defense of the opposite party is that claim has been rejected or repudiated on the plea that new rules of covering pre-existing diseases came in to effect from 01/04/2007 and the complainant’s policy was renewed from 23/03/2007 to 22/03/2008. Therefore, the new rules will not be applicable to the case of the complainant. This argument of the opposite party cannot be acceptable at all. Admittedly, new rules came in to effect from 01/04/2007. The complainant had taken policy right from 2002 to 2003 and his policy got renewed continuously without any break. The relevant policy which was taken on 22/03/2007and it was effective to till 23/03/2008 and during the effective period of this policy, the amendment to the exclusion rule came in to force on 01/04/2007. When the amended rule came into force the policy was in force the benefit of new rule should be extended to the policy holders those who have taken treatment during the effective period of policy. The argument of the opposite party that the new rule is only prospective and not retrospective cannot be accepted. It is not fair and proper to interpret that the claim of the complainant does not fall under the new rule.
The new rule admittedly came into force on 01/04/2007 and under the said rule, the pre-existing diseases are covered. The beneficial amendment to the rule is to be considered liberally in favour of the beneficiary. Policy covering pre-existing diseases shall have to be interpreted to the benefit of the beneficiary. If any doubt arises in the interpretation of rule or statute a interpretation which is favourable to the beneficiary shall have to be given effect. Consumer Protection Act is a social and benevolent legislation intended to protect better interest of the consumers.
The complainant in this case had continuously taken policy right from 2002-03 by paying premium amount. During the effective period of policy he underwent treatment in Wockhardt Hospital and spent amount. The complainant submitted the Hospital bill for Rs. 1,77,239/- and medicine expenses bill for Rs.2,566/. As per the policy in 603900/48/06/8500001472 the sum assured is Rs.1,60,000/-. The amended rule never says that the benefit of amendment will not be applicable for policies renewed during effective period from 23/03/2007 to 22/03/2008. The date of implementation of the rule was 01/04/2007 and on that date the policy of the complainant was in force and it was effective. Therefore, the benefit of the rule shall be given to the complainant since he was holding effective mediclaim policy. In case the mediclaim is rejected for technical reason the very purpose of health insurance will be defeated.
No purpose will be served in taking health policy if the company goes on rejecting the claim on technical grounds. In this case the opposite party company is not justified in repudiating the claim put up by the complainant. Therefore, the complainant is entitled to sum of Rs. 1,60,000/-, the sum assured. The complainant has claimed some more amounts and also compensation for mental agony etc.,. The question of granting compensation for mental agony does not arise. The ends of justice will be met in directing the opposite party to pay Rs.1,60,000/- the sum assured to the complainant. In the result, I proceed to pass the following:-
6. The Complaint is partly allowed. The opposite party is directed to pay Rs. 1,60,000/-(sum assured) to the complainant within 30 days from the date of this order failing which the said amount carries interest at 12% p.a from the date of this order till payment/realization.