- (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. (a) The complainant a doctor by profession took a mediclaim policy with the opposite party on 13.11.1996 for Rs. 55,000. This was being renewed every year without break till 12.11.2000 when the sum insured was increased from Rs. 55,000 to Rs. 3 lakh the complainant s husband s name was excluded and her son s name was included. The complainant consulted a doctor for abdominal pain and was advised to undergo surgery. The opposite party was informed to the effect that the complainant was to undergo a surgery process for Hysterectomy on 12.11.2000 and the same was postponed to 25.11.2000 at Latha Hospital, Kovilpatti, which surgery was done by Dr. Mrs. A. Latha. Ovarian cyst was removed and it was sent for microscopic examination of tumour tissue and histopathology report revealed the presence of cancerous condition and the complainant was advised to undergo treatment for cancer namely chemotherapy/radiotherapy in consultation with an Oncologist. She was admitted on 24.11.2000 and discharged on 3.12.2000. She made a claim dated 15.11.2000 for Rs. 28,169.25 being the medical expenses incurred for hysterectomy. She underwent chemotherapy treatment at Chennai between 18.12.2000 and 12.1.2001 and 15.1.2001 and 18.1.2001 and subsequently at Kovilpatti during January, March, April to June 2001. She had emergency hospitalisation twice during May 2001 and once in June 2001. She incurred expenses and gave claims for Rs. 28,167.85 on 15.12.2000, Rs. 1,10,862.47 on 27.2.2001, Rs. 71,920.23 on 14.5.2001, Rs. 19,602.03 on 17.7.2001 and Rs. 4,635 on 20.9.2001 in all Rs. 2,10,952.53. The opposite party repudiated the claim stating as follows: (i) The complainant enhanced the sum insured under the policy from Rs. 55,000 to Rs. 3 lakh just before the operation, foreseeing the cost of hospitalization expenses. (ii) The operation was scheduled to be done on 12.11.2000 but was postponed to a later date so as to avail the increased cost of hospitalization. (iii) The cytology report said that the complainant was suffering from chronic cervicitis for a long time and it was a pre -existing disease. (iv) The post hospitalization expenses which had been incurred after 60 days from the date of discharge were not admissible under the policy conditions. Hence, the complaint came to be filed.
(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. Per contra, on the side of the opposite party, it was submitted that the increase of sum from Rs. 55,000 to Rs. 3 lakh just before the operation could have been only for the reason that there would be increased cost of post -hospitalization expenses and with a view to avail the increased benefit under the policy. The operation was also postponed to a later date so as to avail the increased cost of post -hospitalization under the renewed policy where the sum insured had been exorbitantly increased to Rs. 3 lakh. The District Forum had rightly held that the complainant was suffering from chronic cervitis for a long time and it was a pre -existing disease. She had been operated for tubectomy 19 years earlier and the cervitis/ovarian cyst could have been the aftermath of tubectomy. Post -hospitalization expenses had been incurred after 60 days from the date of discharge from the hospital which was also not admissible under the policy conditions. It has been held by the National Commission in a, 1997 3 CPJ 101, that where material on record showed that the Insurance Company had fully investigated into the claim and repudiated it, remedy lay with the claimant to approach the Civil Court. The District Forum had rightly dismissed the complaint.;