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2013 DIGILAW 1006 (KER)

Kurian Isac v. United India Insurance Co. Ltd.

2013-11-19

A.V.RAMAKRISHNA PILLAI

body2013
JUDGMENT : A.V. RAMAKRISHNA PILLAI, J. 1. The petitioner has been holding a mediclaim policy issued by the first respondent, for more than 10 years, and he was renewing the said policy year after year. In the year 2007, the petitioner took Ext. P3 policy with effect from 22/09/2007 in continuation of the earlier policies. By that time, the premium amount was enhanced and consequently, there was an increase in the sum assured from Rs.35,000/- to Rs.50,000/-. During the currency of Ext. P3 policy, the petitioner's wife underwent medical treatment involving hysterectomy at Sunrise Hospital, Kakkanad. After the treatment, the petitioner raised a claim for Rs.54,983/-. However, the first respondent paid only Rs.10,000/- and the balance was declined by M/s. T.T.K. Health Care Pvt. Ltd., the Third Party Administrator (TPA) of the first respondent company. The reason pointed that the new policy document contains a restrictive condition of specified illness and, therefore, the claim was restricted to 10% of the total amount. The grievance of the petitioner is that, he was sanctioned a new proposal incorporating such restrictions and he was in darkness about the changed conditions while paying the premium. 2. Though the petitioner approached the Regional Level Committee, the decision of the TPA was upheld and, therefore, the petitioner approached the learned Insurance Ombudsman, who upheld partial repudiation. Thus, the petitioner has come up before his Court. 3. A detailed counter-affidavit has been filed by the first respondent. The stand taken by the respondent insurance company is that the policy issued is not a statutory policy and the terms and conditions are binding on the parties, and their rights and liabilities are also governed by the contract. According to the first respondent, both parties have an option to cancel the policy and the petitioner was duly informed about the terms and conditions. The proposal does not contain the terms and conditions and they are contained in the policy only. According to the first respondent, if the terms were not acceptable, the petitioner could have opted for cancellation of the policy. 4. I have heard the learned counsel for the petitioner and the learned Standing Counsel for the insurance company. 5. The argument advanced by the learned counsel for the petitioner is that Ext. P3 was a continuation of the previous policy and the petitioner was in darkness about the changed conditions while paying the premium. 4. I have heard the learned counsel for the petitioner and the learned Standing Counsel for the insurance company. 5. The argument advanced by the learned counsel for the petitioner is that Ext. P3 was a continuation of the previous policy and the petitioner was in darkness about the changed conditions while paying the premium. According to the learned counsel for the petitioner, the agent also did not disclose the change. It was argued that it is the basic principle of the insurance law that in case of any change or modification of the existing policy, the insurance company should have obtained a signed proposal from the petitioner well in advance. The same contentions were taken before the learned Ombudsman also by the petitioner, and the learned Ombudsman considered the issue in detail. 6. The treatment was given during the currency of the policy issued in 2007. It is true that by issuing the policy, the first respondent had undertaken to cover the risk during a particular year. The validity for each policy is for one year and the benefits under the renewed policy would be as per the conditions of the renewed policy. It is also true that the policy was obtained without submitting a new proposal, but only by paying premium for the subsequent year. 7. The stand taken by the petitioner that he was unaware of the change in the conditions will not stand, as it is admitted by the petitioner that as per the earlier policies, the premium limit was Rs.35,000/- and as per the policies issued in 2007, the sum assured was Rs.50,000/-. The petitioner also paid premium for that amount. Hence, as rightly observed by the learned Ombudsman there was sufficient indication that the first respondent was giving a policy different from the policies issued during previous year. Moreover, in the new policy issued in 2007, it was indicated that the petitioner and his wife are under gold policy and their children are under platinum policy. The classification itself shows that the conditions were revised and it was made known to the petitioner too. 8. In support of the argument, the learned counsel for the petitioner invited my attention to the decision of the Apex Court in Biman Krishna Bose v. United India Insurance Co. The classification itself shows that the conditions were revised and it was made known to the petitioner too. 8. In support of the argument, the learned counsel for the petitioner invited my attention to the decision of the Apex Court in Biman Krishna Bose v. United India Insurance Co. Ltd., 2001 KHC 850 : 2001 (6) SCC 477 : 2001 (3) KLT SN 13 : 2001 (107) Comp Cas 14. It is true that in the aforesaid case, it was observed by the Apex Court that in common parlance, by renewal, the old policy is revived and it is a sort of a substitution of obligations under the old policy unless such policy provides otherwise. 9. The case in hand stands on a different footing. The policy issued in the year 2007 incorporates different conditions and there are sufficient materials to show that the petitioner was aware of the changes. Had it been a case of an automatic renewal, no fresh condition would have been included. 10. As rightly pointed out by the learned Standing Counsel for the first respondent, had the conditions in the renewed policy be not acceptable to the petitioner, he could have very well opted for the cancellation of the policy. That was not done. Therefore, the conditions are binding on the petitioner. 11. The learned Ombudsman has considered the matter in the correct perspective and this Court is of the definite view that the same does not call for an interference in exercise of the powers conferred by this Court under Article 226 of the Constitution of India. Therefore, the writ petition is dismissed. Petition dismissed.