SHERUBEN JAMINDAR Vs. NALINBHAI HIRALAL MODI

JUDGEMENT

(1.) -THE complainant Smt. Parkash Devi took a Mediclaim policy on 2. 12. 1997 by paying a premium of Rs. 1,554 for a period of one year. Subsequently, her husband Bhagwan Das Agarwal and she jointly took a policy for one year (13. 4. 99 to 12. 4. 2000), which was renewed on 7. 6. 2000 with validity up to 6. 6. 2001. During the currency of this policy, Smt. Parkash Devi underwent an operation of the hernia. The claim filed was repudiated by the Oriental Insurance Company stating that under exclusion Clause 4. 3 during the first year of the operation of insurance cover the expenses on surgeries such as cataract, benign prosthetic hypertrophy, hysterectomy for menorrhagia or fibryoma, hernia, hydrocele, congenital internal diseases, fistula in anus, piles and related disorders are excluded. The Insurance Company also contended that there was a gap of 55 days in renewing the Mediclaim policy hence, it can only be construed as a fresh policy. Therefore, the exclusion clause applied to the Mediclaim. Unhappy with the decision of the Insurance Company, a complaint was filed by the complainant before (respondent here) the District Forum, Ranchi.

(2.) THE District Forum held that since the year of surgery was not the first year of the Mediclaim policy of the complainant, she was entitled to the claim amount. The Insurer should not repudiate a claim mechanically and in a routine manner. The District Forum also held that such a view was supported by a decision of the Hon'ble Supreme Court "i (2001) SLT 89=air 2001 SC 549". Accordingly, the District Forum directed the Insurance Company to pay (Rs. 6,257 + Rs. 1,379) i. e. , Rs. 7,636 incurred by the complainant on her treatment during hospitalization.

(3.) AGGRIEVED by the order of the District Forum the Insurance Company filed an appeal before the Jharkhand State Commission, Ranchi. The State Commission, after hearing the parties, concurred with the decision of the Forum.