1. THIS appeal is by Insurance Company against the order dated 14. 9. 2006 passed by the District Forum, Udham Singh Nagar, partly allowing the consumer complaint No. 101 of 2004, for reimbursement of expenses of Rs. 2,08,554 under the Mediclaim policy. Interest @ 8% p. a. w. e. f. 9. 7. 2004 till payment and Rs. 2,000 as cost were also awarded.
2. THE facts of the case, as disclosed from the evidence and material on record, are as under: sh. R. P. Joshi and his wife Smt. Indu Joshi, purchased for the first time Mediclaim policies for sum of Rs. 1,50,000 each for the period 11. 3. 1997 to 10. 3. 1998. For the next year, the policies were renewed from 30. 3. 1998 to 29. 3. 1999 for sum of Rs. 2,00,000 each and for the same amount, the policies were renewed from 30. 3. 1999 to 29. 3. 2000. Policies were again renewed for the said sum for the period 20. 4. 2000 to 19. 4. 2001 and again for the period from 20. 4. 2001 to 19. 4. 2002 and lastly for the period from 20. 4. 2002 to 19. 4. 2003. During the currency of the policy for the period 20. 4. 2000 to 19. 4. 2001, Sh. R. P. Joshi fell sick and continued to be so and even hospitalized at Kashipur and New Delhi even during the period of the renewal policy of the period 20. 4. 2002 to 19. 4. 2003. He died on 19. 8. 2002. Sh. R. P. Joshi had on 26. 7. 2002, submitted an application to the Insurance Company requesting for the payment of the entire amount of expenses incurred in his treatment and the total sum claimed was Rs. 2,75,649. 28. In the application, it was mentioned that the insured had been getting treatment for his ailment from Apollo Hospital, New Delhi and Prashant Nursing Home, Kashipur and in connection with his disease, remained admitted in Prashant Nursing Home, Kashipur from 18. 4. 2001 to 20. 4. 2001; from 19. 8. 2001 to 20. 8. 2001 and from 19. 10. 2001 to 21. 10. 2001. After the death of Sh. R. P. Joshi, his son Sh. Mayank Joshi sent information of the death on 3. 9. 2002 and submitted original bills of the treatment on 26. 12. 2002. Claim having not been finalized and paid, complaint alleging deficiency in service was filed by Smt. Indu Joshi, widow of Sh. R. P. Joshi (insured) for indemnification of the expenses amounting to Rs. 3,00,000 together with interest @ 15%. The complaint was filed on 9. 7. 2004.
The complainant having not completed required formalities and lodging the claim in prescribed form, despite various letters of the Insurance Company, the Divisional Manager of the Insurance Company, by way of his affidavit dated 12. 1. 2005, submitted on the record of the case, informed that due to non-cooperation of the complainant, the claim has been closed as "no CLAIM'' by the Company. The District Forum, however, on 8. 2. 2005, directed the complainant to submit claim form by 7. 3. 2005, which was to be finalized for payment by the Insurance Company by 7. 4. 2005. Complainant vide her application dated 4. 3. 2005 submitted claim form. Per claim form, disease / ailment of Sh. R. P. Joshi was detected on 17. 8. 2001, who was hospitalized w. e. f. 18. 4. 2001 to 19. 8. 2002. Names of the hospitals, mentioned are those, as referred above.
In its written statement, Insurance Company pleaded that the amount of Rs. 1,58,363 was paid to the insured Sh. R. P. Joshi under Mediclaim insurance policy of the period 20. 4. 2000 to 19. 4. 2001 and the amount left under this policy is Rs. 2,00,000 Rs. 1,58,363 = Rs. 41,637 only; that as per claim form, the insured was admitted for treatment of the same illness on 18. 4. 2001 and was discharged on 19. 8. 2002, therefore, the claim falls under the policy covering period from 20. 4. 2000 to 19. 4. 2001; that the documents submitted by the complainant indicate that Sh. R. P. Joshi was admitted in Prashant Orthopaedic Centre, Kashipur from 18. 4. 2001 to 20. 4. 2001 for investigation and CAPD / dialysis as per the instructions of Apollo Hospital, New Delhi and, as such, it was not indicated that Sh. R. P. Joshi was admitted for treatment of a specific disease in the hospital for a minimum period of 24 hours; that as per Clause 2. 3 of the Mediclaim policy, expenses incurred for treatment of disease on hospitalization for minimum period of 24 hours are payable along with medical expenses incurred during period upto 30 days prior to hospitalization and 60 days after hospitalization, as per Clauses 3. 1 and 3. 2 of the policy; that the bills of the expenses submitted do not fall within the perview of the Mediclaim hospitalization policy; that the repudiation of the claim under the policy was by a speaking order and in good faith and that at any rate, the complainant was not entitled to any amount exceeding Rs. 41,637, the remaining amount of total sum insured under the policy for the period 20/4/2000 to 19/4/2001.
3. FOR the disposal of the case on merit, the District Forum had summoned the original record of the case from the Insurance Company and considered the documents in the light of the submissions made by the learned Counsel and also the averments made in the complaint and the written statement. It opined that the date of admission and discharge of Sh. R. P. Joshi in Apollo Hospital, New Delhi were as under:
The various dates of the admission and discharge in connection with the treatment of the ailment of Sh. R. P. Joshi in Prashant Orthopaedic Centre, Kashipur, were as under:
4. IT was also noticed that Sh. R. P. Joshi had to be admitted in Prashant Orthopaedic Centre, Kashipur for providing necessary treatment per diagnosis and instructions given by Apollo Hospital, New Delhi and it was, thus, evident that Sh. R. P. Joshi continued to receive treatment for a period of 30 days prior to the date of his admission on 18/4/2001 and continued to receive the treatment after discharge on 20/4/2001 and thereafter, after every two months, upto the period lasting till 20/4/2002 and, as such, insured Sh. R. P. Joshi, having been admitted and received treatment during the period upto 30 days prior to hospitalization and 60 days after hospitalization, was entitled to be reimbursed for the expenses incurred in terms of the Mediclaim policies and on his death, his widow Smt. Indu Joshi, who had purchased the Mediclaim policy with her husband, became entitled to receive the amount due. On these findings, the Insurance Company was held liable.
We have heard the learned Counsel for the parties and have carefully considered their submissions in the light of the facts, circumstances and the legal aspects of the case. The submissions give rise to the following points for consideration of this appeal:
(i) Whether as per claim form, the insured was not admitted for treatment of a specific disease in the hospital for a minimum period of 24 hours and the claim was not payable in terms of Clause 2. 3 of the policy? (ii) Whether the disease relating to kidney and renal failure, for which the insured used to be admitted in hospital for treatment and CAPD (Dialysis), was not covered under the insurance policy? (iii) Whether the claim made under the Mediclaim policy for reimbursement of the expenses was covered under the policy of the period 20. 4. 2000 to 19. 4. 2001 and claim amount of Rs. 1,58,363 paid by the Insurance Company, absolve it from paying further expenses of hospitalization/treatment of the insured late Sh. R. P. Joshi? (iv) Whether the claim was not payable in view of the terms of Clauses 3. 1 and 3. 2 of the policy, as urged by the Insurance Company? (v) Whether the District Forum was justified in allowing the claim, as stated above? point No. (i)
Copy of the claim form (Paper No. 67/annexure - II to the affidavit of Sh. Atul Tandon, Divisional Manager of the Insurance Company), does not have numbers of columns meant for mentioning date of admission and date of discharge from the hospitals of the insured and it contains only two such columns, as a result of which, the complainant was not in a position to mention each and every date of admission as well as discharge of the period of insurance policy concerned. As mentioned above, insured Sh. R. P. Joshi was required to be admitted in hospitals at New Delhi and Kashipur on six occasions, starting from 18. 4. 2001 to 20. 4. 2001; 19. 6. 2001 to 20. 6. 2001; 19. 8. 2001 to 20. 8. 2001; 19. 10. 2001 to 21. 10. 2001; 19. 12. 2001 to 22. 12. 2001 and 18. 2. 2002 to 19. 2. 2002. Since there were only two columns in the claim form, there appear to be no anomaly in referring to the date of first admission, i. e. 18. 4. 2001 and to mention the date of death as 19. 8. 2002 in the column meant for date of discharge, in order to indicate that the claim for reimbursement of the expenses was confined to the period between 18. 4. 2001 and 19. 8. 2002. The cash memos/bills and the certificates of the hospitals were submitted to the insurer in connection with the claim and the claim file was summoned by the District Forum and on its perusal, the above mentioned dates of the admission and discharge of the insured were verified and referred in the order and which have been, as such reproduced above in this judgment. Therefore, there was neither any infirmity in mentioning the date of admission as 18. 4. 2001 and date of discharge as 19. 8. 2002 in the claim form, nor the verification of various dates of the admission and discharge from the insurance record, nor it would intel inapplicability of the provision of Clause 2. 3 of the insurance policy, which read as under: "expenses on hospitalisation for minimum period of 24 hours are admissible. However, this time limit is not applied to specific treatments, i. e. Dialysis, Chemotherapy, Radiotherapy, Eye Surgery, Dental Surgery, Lithotripsy (Kidney Stone removal), Tonsillectomy, D and C taken in the Hospital/nursing Home and the insured if discharged on the same day, the treatment will be considered to be taken under Hospitalisation Benefit. "
5. THE insured Sh. R. P. Joshi used to be admitted in the hospitals in regard to his treatment for providing CAPD (Dialysis) and in view of the above provision, the time limit of minimum period of 24 hours would not apply, even though the above mentioned dates of admission and discharge on six occasions, indicate that the insured used to be hospitalized also for minimum period of 24 hours. The reason being that after admission, the insured had not been discharged on the same day, but the next day or the day thereafter. Considering these aspects of the matter, we see no merit in the submission of the learned Counsel for the Insurance Company that under the Mediclaim policy, the claim was not payable on the ground that the insured had not remained hospitalized for treatment for minimum period of 24 hours on each and every occasion, as provided under Clause 2. 3 of the policy. The point is answered accordingly. Point No. (ii)
6. THE Insurance Company sought to avoid the maintainability of the claim on the plea that Sh. R. P. Joshi was suffering from kidney failure and was used to be put to dialysis, which was not covered under the terms of the policy. Learned Counsel for the Insurance Company drew attention to copy of the so-called communication dated 12. 1. 2002 (Paper No. 82), also referred thereto in paragraph No. 5 of the memo of appeal, in support of the submission that the claim was not covered under the policy in view of the fact that the disease of kidney and renal failure, was excluded under the terms agreed between the parties. The relevant contents of the said letter, said to have been addressed to the insured Sh. R. P. Joshi, read as under: "as per D. O. Letter No. MOC/doh/1219/01 Dt. 5/9/2001, it is hereby agreed and understood that the policy does not cover the following diseases, i. e. Diabetes Mellitus, Diabetes Nephropathy and hypertension and renal failure disease. . . . . . . . . . . . . . "
According to the learned Counsel, the above exclusion related to the renewed policy for the period 20. 4. 2001 to 19. 4. 2002 and though the claim preferred does not fall under the policy covering the said period, reimbursement of the expenses in view of the said exclusion provision, was not allowable. Learned Counsel for the complainant submitted that no evidence was led to indicate that the letter dated 12. 1. 2002 was received by the insured and at any rate, it being a case of repeated renewal of the medical policies, it was on the same terms and conditions, as were of the original policy. The submission carry conviction in view of the fact that the earlier policies of the insured have not been shown as not covering the above mentioned disease, with which the insured Sh. R. P. Joshi had been suffering since long, as is evident from the certificates of the above mentioned hospitals, submitted on the record of the claim and which had been summoned by the District Forum for perusal. It is also of significance that the Insurance Company came up with the assertion that the claim falls under policy covering period 20. 4. 2000 to 19. 4. 2001, for which sum of Rs. 1,58,363 had already been paid, but it was nowhere shown that the expenses so paid related to insured''s disease other than diabetes mellitus and renal failure, which require dialysis from time-to-time.
In view of above and the admitted fact that the insured and his wife have purchased Mediclaim policies in the year 1997 and thereafter continued to be covered under the renewed Mediclaim policy every year, including the year of the claim submitted in the case and there being no fresh proposal and declaration, we are convinced that the renewal has been on the same terms and conditions, as were of the original policy and terms and conditions of the policy could not have been altered unilaterally by mere submission of the above mentioned letter dated 12. 1. 2002. In regard to this aspect of the matter, it shall be advantageous to refer to the observations of the Hon''ble Apex Court in the matter of Biman Krishna Bose v. United India Insurance Co. Ltd. and Anr. , III (2001) CPJ 10 (SC)=v (2001) SLT 558= (2001) 6 SCC 477, and which read as below: "a renewal of the insurance policy means repetition of the original policy. When renewed, the policy is extended and the renewed policy in identical terms from a different date of its expiration comes into force. In common parlance, by renewal, the old policy is revived and it is a sort of substitution of obligations under the old policy unless such policy provides otherwise. It may be that on renewal, a new contract comes into being, but the said contract is on the same terms and conditions as that of the original policy. "
7. FROM above, there can be no gain-saying that the above legal principle also fully apply to the facts of the case, so as to record the conclusion that the disease relating to kidney and renal failure, was covered under the Mediclaim policy of the insured. The point is answered accordingly. Point No. (iii)
According to the complainant, the claim preferred under the Mediclaim policy of Sh. R. P. Joshi pertains to the policy of the period 20. 4. 2001 to 19. 4. 2002 and whereas, the Insurance Company stuck to the stand that since the insured Sh. R. P. Joshi was admitted for treatment on 18. 4. 2001 and was shown to have discharged on 19. 8. 2002, the claim falls under the policy covering period 20. 4. 2000 to 19. 4. 2001, in regard to which reimbursement to the tune of Rs. 1,58,363 had already been made. It is not in dispute that insured Sh. R. P. Joshi had submitted a claim of Rs. 2,75,649. 28 before his death on 26. 7. 2002 and which is available in the claim record of the Insurance Company summoned by the District Forum. The bills submitted to justify the claim are also on the same record. The Insurance Company has not led any evidence to indicate that the amount of the bills submitted in connection with the claim dated 26. 7. 2002, was the same, which was considered earlier for reimbursement of the claim to the tune of Rs. 1,58,363. Going through the record, it is evident that there was no duplication of the cash memos and the bills and, as such, the Insurance Company has failed to discharge the burden, which lay upon it, to prove that the claim based on these bills had already been finalized and paid against the policy for the period 20. 4. 2000 to 19. 4. 2001.
8. THIS aspect of the matter may also be considered by another angle. The claim record of the Insurance Company has led to the observation by the District Forum that the insured Sh. R. P. Joshi was admitted in the two hospitals, namely, Apollo Hospital, New Delhi and Prashant Orthopaedic Centre, Kashipur and the dates of admission and dates of discharge were verified, as mentioned above in paragraph Nos. 6 and 7 of this judgment. As has been found above, any expenses of the treatment beginning from the date of the admission, i. e. 18. 4. 2001 having not been paid under any claim, the learned Counsel for the complainant rightly submitted that the claim in question was covered under the policy for the period 20. 4. 2001 to 19. 4. 2002 and this was the reason that the bills submitted with the claim pertain to the treatment of the said period. Therefore, the District Forum was fully justified in coming to the conclusion that the claim was covered under the policy for the period 20. 4. 2001 to 19. 4. 2002 and partly under the policy for the period 20. 4. 2002 to 19. 4. 2003 and the submission to the contrary of the Insurance Company was rightly rejected. The point is answered accordingly. Point Nos. (iv) and (v)
The claim preferred was repudiated per endorsement in letter dated 31. 3. 2005 (Paper No. 32 ). The reason given was that the bills submitted with the claim dated 26. 7. 2002 were of the period beyond 60 days of the hospitalisation of the insured Sh. R. P. Joshi and, as such, the claim was beyond the perview of the mediclaim hospitalisation policy. In the written submission with regard to the said reason, reference was made to clauses 2. 3, 3. 1 and 3. 2 of the Mediclaim policy and it was pleaded that the claim was justly repudiated. The terms of Clause 2. 3 of the policy have been considered above under point No. (i ). As regards Clauses 3. 1 and 3. 2 of the Mediclaim policy are these stipulate that relevant medical expenses incurred during the period upto 30 days prior to hospitalisation and during the period upto 60 days after hospitalisation, will be considered as part of claim. Some of the bills submitted were not of the period within 60 days of the hospitalisation and as submitted by the learned Counsel with reference to the written submission of the complainant dated 14. 6. 2006, affidavit dated 12. 6. 2006 of Sh. Manoj Joshi, the son of the insured Sh. R. P. Joshi and written arguments dated 31. 7. 2006 (Paper Nos. 33/1 to 33/2; 34/1 to 34/2 and 36/1 to 36/3 of the original record), it was due to the fact that ''dianeal bags'' and other medicines needed for CAPD/dialysis, were being supplied in North India only by Surya Enterprises of Ghaziabad and these bags and medicines, for being readily available at the time of the required dialysis, were used to be purchased in bulk, so that the insured Sh. R. P. Joshi may be put to proper treatment at the right time. The bills on the record of the claim of the Insurance Company justify the reason put forward on behalf of the complainant and, therefore, in the totality of the circumstances of the case, a rational approach was required to be taken instead of a technical one so far as the interpretation of the above clauses of the Mediclaim policy were concerned as well as the reason for repudiation of the claim by the Insurance Company. In short, the claim could not have been repudiated in view of the terms of the Clauses 3. 1 and 3. 2 of the policy and the District Forum rightly proceeded to determine the amount of reimbursement of the expenses required to be made by the Insurance Company.
As is evident from the various dates of admission and discharge of the insured Sh. R. P. Joshi, the claim was rightly bifurcated by the District Forum, so as to co-relate to Mediclaim policy for the period 20. 4. 2001 to 19. 4. 2002 and partly to the policy for the period 20. 4. 2002 to 19. 4. 2003, keeping in view the term and condition of the policy that Company''s liability in respect of all claims admitted during the period of insurance, shall not exceed the sum insured per person mentioned in the schedule. The policies were of Rs. 2,00,000 each and on the basis of the admissible claim of Rs. 2,08,554 based on the bills submitted as against claim of Rs. 2,75,649. 28 made on 26. 7. 2002, the District Forum rightly went on to award the claim of Rs. 2,00,000 against the policy for the period 20. 4. 2001 to 19. 4. 2002 and remaining amount of Rs. 8,554 of bill dated 20. 4. 2002 against the policy for the period 20. 4. 2002 to 19. 4. 2003. In our view, the claim was rightly allowed to that extent by the District Forum. However, the interest should not have been awarded w. e. f. 9. 7. 2004 in view of the fact, as stated above, that the claim with required formalities was on the asking of the District Forum, submitted on 4. 3. 2005 and the same was directed to be finalized by 7. 4. 2005. The claim was, however, repudiated on 31. 3. 2005 (Paper No. 32) and, as such, the interest could not have been awarded from the date earlier than 31. 3. 2005. To that extent, the order of the District Forum is required to be modified.
9. FOR the reasons aforesaid, the appeal is dismissed. However, the interest @ 8% p. a. on the amount of Rs. 2,08,554, awarded by the District Forum shall be payable from 31. 3. 2005 till the date of actual payment. Rest of the order passed by the District Forum is, hereby, affirmed. No order as to cost. Appeal dismissed.
