T. Suresh v. Oriental Insurance Co. Ltd. New Delhi
2009-12-04
L.NARASIMHA REDDY
body2009
DigiLaw.ai
Judgment :- 1. The petitioner is a medical practitioner in Ayurveda. He took out a Medi-Claim Policy in March, 2002 with the Oriental Insurance Company Limited – the 1st respondent. It was being renewed from time to time on payment of stipulated premium. The petitioner suffered ailment to his Kidney in the year 2005 and surgery had to be conducted. Thereafter, it became necessary to put the petitioner on continuous Ambulatory Peritoneal Dialysis (CAPD), thrice in a day. The monthly expenditure is said to be in the range of Rs.20,000/- to Rs.25,000/-, and this has to continue till the transplantation of the kidney takes place. 2. The medical bills were submitted by the petitioner to the 1st respondent and they have cleared the submitted bills without any demur up to June 2008. However, when the petitioner submitted a claim on 06.06.2008, the 3rd respondent – the Divisional Manager of the 1st respondent, rejected the claim through letter dated 05.09.2008, on the ground that CAPD, which the petitioner was undergoing, was excluded from the coverage. The petitioner feels aggrieved by the action of the respondents. 3. The petitioner contends that the policy is a continuous one and once a particular disease and ailment was covered under the policy, it cannot be excluded during the subsistence of the policy. During the pendency of the writ petition, the petitioner remitted the premium of Rs.7,293/- on 16.03.2009, for renewal of the policy for the year 2009-10. However, it was not accepted on the ground that the ailment, which the petitioner was undergoing, is no longer under the coverage. W.P.M.P.No.14778 of 2009 is filed in that connection. Reliance is placed upon the judgment of the Supreme Court in United Indian Insurance Company Limited v. Manubhai Dharmasinhbhai Gajera (1) AIR 2009 SC 446 = 2008 (8) SCJ 823. 4. On behalf of the respondents, counter affidavit is filed. It is stated that the duration of the policy is only for one year, and though it is renewed year after year, it cannot be treated as a continuous one. According to the respondents, once a particular disease or ailment is excluded from the coverage, the petitioner cannot claim reimbursement for the treatment thereof. 5. Heard Sri. P. Vinod Kumar, learned counsel for the petitioner and Sri N. Mohan Krishna, learned counsel for respondents. 6. The petitioner took out the Medi-Claim Policy, way back in the year 2002.
According to the respondents, once a particular disease or ailment is excluded from the coverage, the petitioner cannot claim reimbursement for the treatment thereof. 5. Heard Sri. P. Vinod Kumar, learned counsel for the petitioner and Sri N. Mohan Krishna, learned counsel for respondents. 6. The petitioner took out the Medi-Claim Policy, way back in the year 2002. It is rather unfortunate that a disease, which had a severe impact on the individual for the rest of his life, has occurred to the petitioner. Expenditure had to be incurred, not only for conducting operation to the kidneys, but also for the Dialysis, which is almost a routine. The existence of policy for the petitioner provided financial relief, though his suffering remain. The respondents discharged their obligation under the policy by reimbursing the cost incurred by the petitioner towards treatment, be it for Dialysis or medicines. It is only for the year 2008, that they refused to honour the claim of the petitioner on the ground that it was excluded from the list, with effect from the year 2008. 7. It is no doubt true that the duration of the coverage under the policy is one year. Clause 2.18 of the policy makes this very clear. However, Clause 3 of the policy, dealing with the renewal, confers a right on the policyholder to seek renewal on payment of the premium. The clause reads as under. 3. Renewal of Policy: Company shall not be responsible or liable for non-renewal of policy due to non-receipt or delayed receipt (i.e. After the due date) of the proposal form or of the medical practitioners report wherever required or due to any other reason whatsoever. Standing this, however, the decision to accept or reject for coverage any person upon renewal of this insurance shall rest solely with the Company. The company may as its discretion revise the premium rates and/or the terms & conditions of the policy every year upon renewal thereof. Renewal of this policy is not automatic; premium due must be paid by the proposer to the company before the due date. Company normally sends renewal notice, but not sending it will not tantamount to deficiency in service. 8. The very first sentence gives an indication that in case the premium is paid without delay, renewal becomes a matter of course.
Company normally sends renewal notice, but not sending it will not tantamount to deficiency in service. 8. The very first sentence gives an indication that in case the premium is paid without delay, renewal becomes a matter of course. It is not alleged that the petitioner delayed the payment of premium at any point of time. Once the policy was taken and it is being renewed from time to time, it virtually becomes a continuous phenomenon, and any changes as to the coverage that takes place in between, would not apply to the policyholder. The change, as regards coverage, may apply to those persons who take out a policy for the first time or where, their existing policy is elapsed and a necessity has arisen to take out a fresh policy, after it. 9. A Division Bench of High Court of Gujarat dealt with similar terms, as to renewal of policy was taken into account. It was held that the intermittent changes, as to coverage, do not apply, if the renewal of the policy is without any break. The conclusions of the Bench were summed up in Para 38 and they read as under. “The insured has an option under the existing medi-claim insurance policy to continue the cover by payment of renewal premium in time in respect of the sum insured. In case of renewal without break in the period, the medi-claim insurance policy will be renewed without excluding any disease already covered under the existing policy which may have been contracted during the period of the expiring policy. Renewal of mediclaim insurance policy cannot be refused on the ground that the insured had contracted disease during the period of the expiring policy so far as the basic sum insured under the existing policy is concerned”. (Remaining portion of the paragraph is not necessary for the purpose of this case) 10. It was held that being Insurance Company wholly owned by the Government of India, the respondents answers the description of the State that the writ petition is maintainable. The principle laid down by the High Court of Gujarat was upheld in United India Insurance Company Limited (1 supra). 11.
It was held that being Insurance Company wholly owned by the Government of India, the respondents answers the description of the State that the writ petition is maintainable. The principle laid down by the High Court of Gujarat was upheld in United India Insurance Company Limited (1 supra). 11. The contentions advanced on behalf of learned counsel for the petitioner that the exclusion was not approved by the Insurance Regulatory and Development Authority, does not merit consideration at this stage, particularly, when relief is being granted on other grounds. 12. For the foregoing reasons, the writ petition is allowed directing that (a) the petitioner shall be entitled for reimbursement for the diseases that are included in the policy taken out by him on 21.03.2002, and that exclusion of any disease from the list does not affect the rights of the petitioner to claim reimbursement; (b) The petitioner shall be entitled for the renewal of the policy as long as the premium for renewal is paid within the stipulated time. This however, shall be subject to the right of the respondents to refuse the renewal on any other grounds that are available for them in law. There shall be no order as to costs.