United India Insurance Co. Ltd. vs RAM KUMAR GOYAL

THIS is an Insurance Company''s appeal against the judgment and order dated 28.1.2000 passed by the District Forum, Haridwar in Complaint No. 130/1998, Ram Kumar Goyal v. United India Insurance Co. Ltd.

THE brief facts of the case are that Shri Ram Kumar Goyal has obtained a Medi Claim Policy for himself and his wife which was effective from 22.4.1993 to 21.4.1994. In February, 1994, he felt some pain in the eye and on 9.2.1994, he got his eyes examined at Shraf Eye Centre, Delhi who advised for operation and the date of operation was fixed to be on 28.2.1994. THE complainant informed this fact to the Insurance Company vide letter dated 12.2.1994. THE operation was conducted on 28.2.1994 and the complainant remained hospitalised for two days. She spent a sum of Rs. 12,659.54 in his treatment which he is entitled to get from the Insurance Company. Since the claim has been repudiated, the complaint was filed in the Forum. THE learned Forum allowed the complaint against which order, the present appeal has been filed. THE appeal has been contested merely on two grounds. Firstly, that the claim is barred by time. Secondly, the treatment of cataract is not admissible in the insurance policy during its first year as per terms and conditions of the policy. We have heard the learned Counsel for the parties and gone through the records. It is alleged that the claim has been repudiated on 18.5.1994 and the claim petition has been filed on 26.7.1998. Therefore, it is barred by time. According to the complainant, he has sent a letter on 5.12.1994 to the Insurance Company. It was not replied. The learned Counsel for the appellant argued that since the claim has been repudiated on 18.5.1994, any subsequent letter will not extend limitation. But the fact remains that by the letter dated 5.12.1994, the complainant informed the Insurance Company that Dr. Shraf has charged Rs. 7,500/- which includes the cost of lens implanted in his eye. No split was given. If he likes he may verify from Dr. Shraf. On 1.12.1994 the Insurance Company has written to the complainant that the superior officer has sought following clarifications i.e., detailed break-up of Rs. 7,500/- and it was informed that on receipt of the reply of the complainant, the Company will proceed further. It was argued that the claim has already been repudiated on 18.5.1994 and any subsequent letter will not extend limitation. But this letter of 1.12.1994 has specifically shown that the matter was pending with the superior officers of the Company and was still to proceed. Further on receipt of the reply of the complainant. Therefore, the repudiation order dated 18.5.1994 is of no value. When the matter, again, is under consideration by the superior authority. Merely by writing any prejudice or admission of any liability, the Company cannot be absorbed of the liability. The question here is not of liability. The question is here, whether the matter is still under consideration and it is specific in letter that the matter is still under consideration. So is the condition with earlier letters of the Insurance Company dated 18.8.1994 and other letters on which, too, without prejudice has been written. Again to emphasise, the question is of extension of limitation. Thereafter, nothing has been heard by the complainant and naturally he will wait for some reasonable time and then will file the complaint. If seen in this light, the claim is not barred by time. The complainant has also written a letter on 29.8.1995 calling for final decision. In this light, the petition is within time.

As regard the second condition i.e. exclusion clause, in the earlier policy, nothing like Exclusion Clause was given. Lock-in period was only shown as one month. It is by a subsequent amendment that the Exclusion Clause has been added which is not at all binding on the complainant. This is an ex parte amendment in the policy and subsequent information will not entitle the appellant to use this Exclusion Clause because the insurance is a contract between the parties. Its terms and conditions cannot be varied under renewed ex parte policy. The policy by which the case of the claimant shall be governed, does not bear any such Exclusion Clause. As a result, this appeal has got no force and is to be dismissed. ORDER The appeal is hereby dismissed. However, cost of the appeal shall be easy. Appeal dismissed.