BADRUDDIN KHOKKAR v. UNITED INDIA INSURANCE CO, LTD.
2006-08-23
R.S.AWASTHI, V.K.AGARWAL, VEENA MISRA
body2006
DigiLaw.ai
ORDER As per Hon'ble Justice Shri V.K. Agarwal, President:- 1. This appeal under section 15 of the Consumer Protection Act 1986, is directed against the order dated 21.03.2006 in complaint No. 128/2005 by District Consumer Disputes Redressal Forum. Raipur (hereinafter called "District Forum" for short) dismissing the appellant's complaint where in compensation under Medi-claim policy was sought by the complainant. 2. Indisputably the complainant had obtained a Medi-claim policy No. 190501/48/00313 from the respondent/insurer. The policy was effective for the period from 20.08.2004 to 19.08.2005 Admittedly. Rs. 3720/- was paid by the complainant towards premium of the said policy. The complainant subject to terms and conditions of policy was entitled to the benefit to the extent of Rs. 3,00,000/-. 3. The complainant's case stated in brief was that after obtaining the policy, he had some medical problem on 2.9.2004, therefore he got himself examined at MMI Hospital, Raipur where Dr. SA Kale examined him and diagnosed that he was suffering from kidney problem. According to the averments in the complaint, the complainant had to remain admitted in the hospital for diagnosis and treatment as above, from 2.9.2004 to 4.9.2004. Thereafter he was asked to come after admitted in MMI Hospital for treatment of kidney on 8.10.2004. Thereafter surgery was performed and his kidney was traspranted on 10.10.2004. He remained admitted in MMI Hospital till 23.10.2004. The complainant averred that he had to incurred expenditure of about Rs.4,00,000/- He submitted the claim with the respondent/insurer for payment of Rs. 3,00,000/- under the Medi-claim policy. Since the said amount was not paid; after serving legal notice on 1.2.2005 to the respondent/insurer, he preferred complaint in the District Forum. 4. The complaint was resisted by the respondent/insurer. The averments of the insurer were that by the contract of insurance it was stipulated between the parties that in case any disease was detected within thirty days after obtaining the policy, the claim regarding such disease would be excluded. It was averred that as per exclusion clause No. 4.2 of the policy, the claim of complainant was not payable as after obtaining the policy on 20.08.2004 the disease as per the submission of, the complainant itself detected on 2.9.2004 i.e. within thirty days after obtaining the policy. Accordingly the complainant was not entitled to the claim. 5.
It was averred that as per exclusion clause No. 4.2 of the policy, the claim of complainant was not payable as after obtaining the policy on 20.08.2004 the disease as per the submission of, the complainant itself detected on 2.9.2004 i.e. within thirty days after obtaining the policy. Accordingly the complainant was not entitled to the claim. 5. District Forum upheld the contentions of her respondent/insurer as above and held that the exclusion clause contained in the policy applies and therefore by rejecting the claim of the complainant, the respondent/insurer did not commit any deficiency in service. The complaint was accordingly dismissed by the District Forum. 6. We have heard the learned counsel for the parties and perused the record. 7. The learned counsel for complainant/appellant submitted that the terms and conditions in case of the policy document as produced in the District Forum did not form part of the policy and that only one page policy was issued to the complainant. However the contention as above is demolished by the averments in his notice (Annexure A.18) which clearly states that terms and conditions formed part of the policy which was issued to the complainant. It may be mentioned that the policy document (Annexure-NA-1) also clearly states that terms of policy are annexed therein. In view of the above as also from averments in the notice. It is clear that the terms and conditions constituted part of the policy and were duly furnished to the complainant. 8. The next contention of learned counsel of complainant/appellant was that the terms of policy did not exclude the expenditure on the treatment undertaken by the complainant. It was submitted in the above context that the actual treatment of complainant stated from 8.10.2004. However the averments in the complaint in paras 3 and para 7 would disclose that complainant suffered form physical problem and was admitted in MMI Hospital form 2.9.2004 to 4.9.2004 and was detected to be suffering from kidney problem. This is also supported by several documents placed on record. Therefore it is clear that the kidney problem was detected on 2.9.2004 i.e. within thirty days of the day, on which policy was obtained. The exclusion clause No. 4.2 of the policy reads as below:- "Exclusion clause 4.2.
This is also supported by several documents placed on record. Therefore it is clear that the kidney problem was detected on 2.9.2004 i.e. within thirty days of the day, on which policy was obtained. The exclusion clause No. 4.2 of the policy reads as below:- "Exclusion clause 4.2. Any disease other than those stated in clause 4.3 contracted by the insured person during the first thirty days from commencement date of the policy. This condition 4.2 shall not however, apply in case of the insured person having being 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. 9. It would therefore be clear that since the disease was detected within thirty days from commencement date of the policy, there for, in view of above explicit exclusion clause, the complainant is not entitled to any claim under the policy. Learned counsel for the appellant relied upon the decision of Apex Court in United India Insurance Co. Ltd. Vs. M/s Pushpalaya Printers wherein it has been laid down that if two interpretations of a document are possible, then the documents shall be construed in the manner, which is beneficial to the insured and against the party who prepared it. However in the instant case, the exclusion clause as above is in unambiguous terms and there cannot be two interpretations regarding the meaning thereof. Therefore, the citation as above would not render any assistance to the complainant's case. 10. Therefore the finding of the District Forum that the repudiation was justified in view of the exclusion clause quoted above appears to be based on proper appreciation of facts and circumstances of the case as well as material placed on record. It calls for no interference. 11. Learned counsel for the complainant/appellant relied upon the decision of National Commission in M/s Atlas Exports India Vs. Divisional Manager, New India Insurance Co. Ltd. 2 in which it was observed that since that policy did not include exclusionary clause limiting liability of the opposite party hence anything not included in the policy would not govern the rights of the parties. However the fact situation in the instant case in entirely different.
Divisional Manager, New India Insurance Co. Ltd. 2 in which it was observed that since that policy did not include exclusionary clause limiting liability of the opposite party hence anything not included in the policy would not govern the rights of the parties. However the fact situation in the instant case in entirely different. The defense of insurance company is based on terms in the exclusionary clauses of the policy which accompanied the policy and formed part there of Hence the ratio of the above cited decision, does not apply to the present case. 12. Learned counsel for the appellant relied upon another decision of National Commission in New India Insurance Co. Ltd. Vs. Vasant Rao3 where, on facts it was held that there was no material suppression as the earlier treatment and ailment was in the year 1986 while the claim was made for the disease suffered in 1999. It was held therein that later disease was not continuation of the previous disease. On facts, the present case is on entirely different footing. Hence the decision as above does not render any assistance to the complainant's case. 13. Learned counsel for the appellant also relied upon the decision of Madhya Pradesh State Commission in New India Insurance Co. Ltd. Vs. Vimal Chand Jain in which it was held that burden of proving material suppression is on the insurer. The proposition as above cannot be disputed. However, in the instant case, it is clear that the averments in the complaint itself, disclose that the disease was detected within thirty days of the commencement of the policy. Therefore, the repudiation as per terms of policy will have to be treated as proper and justified. 14. Another decision of M.P. State Commission was relied upon by the learned counsel for the appellant in Harbans Singh Sohal Vs. The Divisional Manager, The Oriental Insurance Co. Ltd.; the state Commission on appreciation off acts of the said case held that, there was no material suppression of facts. However, in the instant case as has been pointed out earlier, detection of disease within thirty days has been established by the admission of complainant himself. Thus, it is clear that the repudiation by the insurer was justified, in view of the exclusionary clause of the medi-claim policy, obtained by the complainant. 15.
However, in the instant case as has been pointed out earlier, detection of disease within thirty days has been established by the admission of complainant himself. Thus, it is clear that the repudiation by the insurer was justified, in view of the exclusionary clause of the medi-claim policy, obtained by the complainant. 15. For the same reason the decision of Uttranchal State Commission in United India Insurance Co. Ltd. Vs. Kapil Kumar, as also of Delhi Commission in United India Insurance Co. Ltd. Vs. Mehtab Singh relied upon by the learned counsel for appellant cannot lend any support the stand of the complainant appellant. In another decision Delhi State Commission in Life Insurance Corporation of India Ltd. & Drs. Vs. A.K. Kalra relied by the complainant/appellant, it was held that concealment of disease which did not have direct nexus with the cause of death would not amount to concealment of material facts and therefore the repudiation was not justified. However on facts the ratio of the said case also does not help the complainant/appellant. 16. The learned counsel for appellant has also cited the decision of Karnataka State Commission in Oriental Insurance Co. Vs. K. Anandam wherein claim of the complainant was repudiated under the exclusion clause of the policy. The State Commission after considering the circumstances of the case held that the repudiation as above was not justified. However in the instant case it is clear that the exclusion clause clearly justified the repudiation. Hence the ratio of the citation as above would not be of any assistance to the complainant. 17. Accordingly, we find no infirmity in the impugned order. The same is affirmed. The appeal is dismissed. However the parties shall bear their own cost. Appeal Rejected.