UNITED INDIA INSURANCE COMPANY LIMITED Vs. PRADEEP KUMAR

JUDGEMENT

(1.) THIS appeal has been preferred against the judgment dated 31.5.2010 passed by the District Forum, Sirohi by which the complaint of the complainant was allowed. Brief facts of the case are that the respondent -complainant took a mediclaim policy from appellant No. 1 in the year 2001 and this policy was renewed every year till the year 2007. In the year 2008 the appellants renewed the policy of the respondent covering his family members also. Of course a fresh proposal form was obtained from the respondent and policy was renewed from 16.9.2008 to 15.9.2009. On 9.1.2009 the respondent was operated upon for Hernia and he spent Rs. 1,02,662. He claimed the amount from appellant No. 1 under the policy but he was paid only Rs. 22,500. The case of the appellants was that under the family mediclaim policy the expenses on certain diseases including Hernia was restricted upto 15% of the sum assured subject to maximum limit of Rs. 30,000. The District Forum rejected the contention of the appellants and ordered reimbursement of full expenses.

(2.) THE learned Counsel for the appellants has argued that previously in the year 2001 the respondent was taking individual mediclaim policy and in the year 2008 he had taken family mediclaim policy and he is bound by the conditions of the new policy. Refuting the arguments of the appellants, the learned Counsel for the respondent has argued that this policy was being continued since 2001 and in the year 2008 the respondent was offered a family care policy without clarifying any change in conditions though a new proposal form was obtained but he was never informed of the terms and conditions. In the old policy there was no restriction of expenses of Hernia, therefore, he is entitled for the full amount. He has cited , Vikram Grentech (I) Ltd. and Anr. v. New India Assurance Co. Ltd., 2009 2 CPJ 34

(3.) I have heard the contention of both the sides. The District Forum has held that at the time of renewal in the year 2008 the respondent was never informed or explained the change in conditions. Though new proposal form was obtained from him but there is no evidence that he was explained the change in conditions. I am of the view that the District Forum has committed no illegality in holding this view. On perusal of the proposal form it was found that old policy number was also mentioned in that proposal form and the respondent was naturally under the impression that there has been no change in the conditions. Otherwise his policy was also continuing for the last eight years without any claim.