ORIENTAL INSURANCE CO LTD Vs. K J HOSPITAL

JUDGEMENT

(1.) This is a Revision Petition against the Order dated the 17th August, 1992 passed by the State Consumer Disputes Redressal Commission, Madras in A.P. No. 250 of 1990 by which the order of District Forum, Madras was set aside and the present Revision Petitioner, M/s. Oriental Insurance Co. Ltd. was ordered to pay Rs : 82,000/- to claimant No. 1 with interest at the rate of 12 per cent per annum from 19th December, 1989 till payment. Costs were also awarded to the claimants.

(2.) The brief facts are that the complainant No. 2, Mr. A. Samsukani, (Now Respondent No. 2) had taken a med-i-claim policy from the petitioner-company for the period from 14th October, 1988 to 13th October, 1989 for the benefit of his son S.Aliar. However, on the expiry of the said period of the policy it was not renewed immediately. It was renewed after a gap of a couple of days i.e. from 17.10.1989 to 16.10.1990. The said Aliar was admitted in the first Respondent's hospital i.e. M/s. K.J. Hospital (which was complaint No. 1 in the complainant) on 8th November, 1989 and it was found that he was suffering from Aortic Regurgitation, mild pulmonary Hypertension, Mild Mitral Regurgitation and Rheumatic Etiology. He was advised to undergo Aortic Valve Replacement. The 1st Complainant sent a letter to the Insurance Company to know whether the patient was entitled for reimbursement. There was no. reply and as the matter was urgent the Insurance Company was contacted on phone and the 1st Complainant is alleged to have been informed that the patient was entitled to the benefits under the med-i-claim policy. Consequently, he was operated upon on 9th December, 1989. The Hospital lodged a claim for Rs. 82,000/- under the med-i-claim policy with the Insurance Company. The claim was rejected on the ground that the policy then in force was not a renewed policy but a fresh one and as the illness of the patient occurred within a month from the date of the commencement of the policy, the claim was not maintainable. Aggrieved thereby, the complainants filed the complaint under the Consumer Protection Act, 1986, before the District Forum, Madras claiming Rs. 82,000/- from the Insurance Company.

(3.) The complaint was contested by the Insurance Company and the main ground was that it was a fresh policy as it was taken after a break of a couple of days on the expiry of the previous policy and, therefore, in view of the exclusion clauses, the Hospital was not entitled to claim under the policy. The Exclusion Clause reads as follows :