ASHOK KUMAR GARG vs United India Insurance Co. Ltd.

THE present appeal, filed by the appellant, under Section 15 of the Consumer Protection Act, 1986 (hereinafter referred to as the Act), is directed against order dated 21.2.2003, passed by District Forum (Central), Maharana Pratap Bus Terminal, Kashmere Gate, Delhi in Complaint Case No. 843/2002 entitled Shri Ashok Kumar Garg v. M/s. United India Insurance Company Limited.

THE facts, relevant for the disposal of the present appeal, briefly stated, are that the appellant Shri Ashok Kumar Garg had filed a complaint under Section 12 of the Act before the District Forum averring therein that the appellant had obtained a Mediclaim Policy from the respondent for Rs. 1,50,000/- for the period from 21.10.2001 to 20.10.2002. In the complaint, filed by the appellant, it was stated that in the proposal form, submitted by the appellant, at the time of taking the policy in question, the appellant had mentioned that the appellant got replaced and transplanted his valves in the heart in the year 1981 and 1988 at Bombay Hospital. It was stated that in the month of October, 2001 the appellant fell ill and was taken to Apollo Hospital where the appellant remained admitted from 29.10.2001 to 10.11.2001 for clots appearing in the brain. It was stated that for the above treatment, the appellant had incurred an expenditure of Rs. 1,28,000/- including the cost of medicines. It was stated that a claim under the above said policy was preferred by the appellant with the respondent but the same was repudiated by the respondent on the ground that the same fell under the exclusion clause of the policy as the appellant had not disclosed the pre-existing disease before taking the above said policy. THE appellant, in the complaint filed by him, had prayed that the respondent be directed to pay the amount of Rs. 1,28,000/- to the appellant together with interest @ 18% per annum from 10.11.2001. THE appellant had also claimed cost of litigation including the cost of serving legal notice on the respondent. The claim of the appellant in the District Forum was resisted by the respondent. In the reply/written version, filed on behalf of the respondent, the respondent had taken certain preliminary objections to the effect that the controversy involves determination of complicated questions of facts and law, requiring elaborate oral and documentary evidence; that the complaint, filed by the appellant, was misconceived as the claim had been repudiated by the respondent after due application of mind. On merits it was stated that after the receipt of the claim from the end of the appellant the same was referred to doctors on the panel for expert opinion. It was stated that the doctors on the panel of the respondent after going through the relevant papers had opined that the appellant had an embolic (dislargement of clot) episode from the prosthetic (artificial) valve fitted in arotic position and that the appellant had undergone first operation of arotic valve replacement in 1981 followed by the replacement of the same in the same position by a mechanical valve in 1988. It was stated that the above said doctors had opined that the complication of vertibro basilar territory was because of inadequate hypo coagulation as the dose of blood thinning tablet could not be increased because of bleeding piles. It was stated that thrombo embolic episode had a link with prosthetic valve and hypo coagulation. It was stated in the reply filed on behalf of the respondent that the complaint filed by the appellant was devoid of substance and deserved to be dismissed.

The learned District Forum vide impugned order has held that the respondent while repudiating the claim of the appellant has not committed any infirmity. On the basis of the above finding the learned District Forum has dismissed the complaint, filed by the appellant leaving the parties to bear their own costs.

FEELING aggrieved, the appellant has preferred the present appeal under Section 15 of the Act. We have heard the learned Counsel for the appellant at length on the question of admission of the present appeal and have also carefully gone through the documents/material on record. On the basis of documents/material on record it is not in dispute that the appellant had taken a Mediclaim Policy from the respondent for the period from 21.10.2001 to 20.10.2002 for Rs. 1,50,000/-. It is also not in dispute that the appellant had preferred a claim under the policy for Rs. 1,28,000/- being the cost of treatment and medicines which the appellant had taken from Appollo Hospital where he remained admitted from 29.10.2001 to 10.11.2001. It is also not in dispute that the claim preferred by the appellant has been repudiated by the respondent on the ground that the same fell under the exclusion clause of the terms and conditions of the policy as the appellant did not disclose the pre-existing disease at the time of taking the above said policy.

THE short question requiring consideration by us in the present appeal is as to whether the repudiation of the claim, preferred by the appellant under the policy by the respondent, was just and proper or the same suffers from any infirmity so as to call for any interference by this Commission in exercise of its appellate powers. On the basis of material on record it is not in dispute that condition No. 4(1) of the policy in question provides in clear-cut terms that any complications arising from pre-existing disease will be considered as part of pre-existing disease. The learned District Forum while passing the impugned order has placed reliance on the expert opinion of two cardiologists, namely, Dr. A.K. Aggarwal and Dr. H.K. Chopra, Head of the Department of Medicines and Cardiology, Moolchand Khairati Ram Hospital, New Delhi. Both the above mentioned doctors, who are specialists in their own field, have opined that complications to the brain had direct linkage with the complications from which the appellant was suffering earlier. There is nothing on record to rebut the above opinion expressed by the experts with regard to pre-existing disease. In the presence of the above facts, no fault can be found with the findings of the learned District Forum. The order, being impugned in the present proceedings, is a well reasoned order which suffers from no infirmity so as to call for any interference by this Commission in exercise of its appellate powers. The present appeal, filed by the appellant, is therefore, devoid of substance. The same merits dismissal. Accordingly, the same is dismissed in limine with no order as to costs. Appeal dismissed.