RADHA PALANIAPPAN Vs. ORIENTAL INSURANCE COMPANY LIMITED

JUDGEMENT

(1.) THE complainant in C.O.P. No. 48/2001 on the file of the District Consumer Disputes Redressal Forum, Tuticorin, is the appellant herein.

(2.) THE District Forum by order dated 29.11.2001 dismissed the complaint holding that the complainant was aware at the time of renewal of policy on 12.11.2000 that she had ovarian tumour on 6.11.2000 itself. This fact had been suppressed at the time of renewal and that the hospital in which the complainant had got treatment was not prima facie in conformity with policy condition Clause 2(1)(a). It is as against that the present appeal has been filed.

(3.) MR . Natarajan, learned Counsel for the appellant/complainant submitted that the District Forum had totally mis -directed itself in the appreciation of the facts and documents placed before it. The District Forum had not properly adverted to Ex. B13 dated 1.6.2001 given by Dr. Latha who treated the complainant. The doctor had also clarified that the overial cyst could very well have begun as non -cancerous cyst and had a high probability of having undergone a cancerous change and it would be hard to answer as to when such change might have occurred. There was no contra materials produced on the side of the opposite party. The opposite party was not justified in taking a view that the complainant was operated for tubectomy 19 years earlier and cervicitis/ovarian cyst might be the after effect of tubectomy. There was absolutely no justification on the part of the opposite party to say that the disease pre -existed prior to commencement of policy in 1993. The National Commission has in LIC of India v. S. Hymavati, held that the disease suffered 15 years ago but cured and not disclosed the proposal form would not attract the provisions of non -disclosure. As regard the increase in the insured sum from Rs. 55,000 to Rs. 3 lakh, it was submitted on behalf of the complainant that the sum insured under the insurance policy was enhanced only in order to claim tax benefits under Section 80D of the Income Tax Act and there was no knowledge of the disease or the complications thereunder. The premium cheque for Rs. 4,073 dated 3.11.2000 was given to the opposite party towards enhanced sum insured and was accounted on 7.11.2000 by the opposite party at their own convenience and the policy was issued with effect from 12.11.2000 when the complainant had no knowledge about the illness or ovarian cyst on 3.11.2000 it was strange to conclude that the enhancement of sum insured could not be considered. As regards the non -registration of the hospital and the number of beds, the reduction in bed capacity was duly explained by the hospital authorities and the same could not be allowed to be misinterpreted by the opposite party for denying the claim. In the hospital, originally the bed strength was 10 and since they had moved to temporary accommodation to facilitate the construction of a new building for the hospital and for technical convenience the bed capacity was reduced to 6 beds only. The District Forum was in error in refusing to pay the compensation. As regards the issue relating to post -hospitalization, the opposite party was not justified in saying that the treatment taken subsequent to discharge on 3.12.2000 should be treated as post -hospitalisation treatment that under medi -claim policy Clause 2.3 claims in respect of treatment relating to dialysis, chemotherapy/radiotherapy, etc., taken in a hospital the insured need not stay in the hospital for 24 hours. The complainant in the instant case had stayed for more than 24 hours in the hospital. Each hospitalization should be treated as separate hospitalization and they cannot be clubbed together.