- (1.) THIS appeal arises from order dated 7.12.2001 rendered by the learned Consumer Disputes Redressal Forum, Rajkot in Complaint No. 22 of 2000 directing the opponent Insurance Company to pay to the complainant permissible amount against the claim of Rs. 1,51,845.30 in respect of the bye -pass surgery undergone by the insured complainant under the mediclaim insurance policy in question with interest at the rate of 10% p.a. from 12.8.1999 and cost quantified at Rs. 1,250/ -.
(2.) WE have heard the learned Advocate appearing for the Insurance Company. We have gone through the impugned order. No one has remained present for the original complainant, now the respondent. It is not in dispute that the insured had mediclaim policy for Rs. 55,000/ - for the period 1.7.1998 to 30.6.1999 and the insured had availed of indemnity under the said policy in respect of the angioplasty undergone by him in Rajasthan Hospital during 9.11.1998 and 1.12.1998. It is also not in dispute that when he once again had taken mediclaim policy on or around 25.1.1999 for Rs. 2,50,000/ - he did disclose the ailment of heart and angioplasty having been undergone at Rajasthan Hospital under the current policy. Yet, the opponent Insurance Company issued policy for Rs. 2,50,000/ -. The complainant had thereafter undergone angiography and bye -pass surgery respectively on 13.4.1999 and 17.4.1999 and he remained hospitalised between 17.4.1999 and 26.4.1999. It was this operation which resulted into submission of the claim in question by the complainant to the opponent Insurance Company. Opponent Insurance Company repudiated the claim on the ground that it was hit by exclusion Clause 4.1. It has been submitted that the learned Forum erred in viewing the matter from the point of view of suppression of material fact. Repudiation was based on the exclusion clause noted hereinabove. Hence, the opponent Insurance Company has challenged the impugned order before this Commission.
(3.) THE exclusion Clause 4.1 would read as 'all diseases, injuries which are pre -existing when the cover incepts for the first time'. It has been submitted that policy for Rs. 2,50,000/ - taken by the insured was fresh policy and, therefore, the pre -existing ailment of heart was excluded. In our considered opinion, at least to the extent of Rs. 55,000/ - for which the insured had already cover, the second cover amounted to removal of the mediclaim policy or it can well be said that the cover did not incept for the first time to that extent. This Commission had an occasion to take similar view of this clause in Appeal No. 592 of 2001 between Ashvinbhai Narandas Doshi and Anr. v. United India Insurance Co. Ltd., decided on 9.12.2003. We are not able to agree with the finding insofar as any amount more than Rs. 55,000/ - is concerned as for such an amount, the insurance can appropriately be said to be first insurance or fresh insurance and it could not be said that such a cover for excess amount would incept for the 2nd time or for successive periods.;