Khimanibai Sohanlal Mehta vs NEW INDIA INSURANCE COMPANY

THIS revision petition has been filed by the petitioner against the order dated 30.04.2013 passed by the Gujarat State Consumer Disputes Redressal Commission, Ahmedabad (in short, ''the State Commission'') in Appeal No. 668/2009 Mrs. Khimanibai Sohanlal Mehta Vs. The New India Assurance Co. Ltd. and Anr. by which, while dismissing appeal, order of District Forum dismissing complaint was upheld.

BRIEF facts of the case are that Complainant/petitioner is taking medi -claim insurance policy from OP/respondent since last 15 years and getting insurance renewed by paying premium. During currency of policy, insured was admitted in Mahavir hospital and was discharged on 20.12.2004. As per opinion of the hospital, angiography and angioplasty was done on 6.1.2005 and claim of Rs.2,66,814/ - was submitted to OP in 2005. It was further submitted that on account of heart problem complainant was again admitted in Mahavir hospital on 3.9.2005 for angiography and angioplasty and was discharged on 8.9.2005 and incurred expenses of Rs.2,34,817/ -. Complainant submitted total claim of 5,01,632/ - to OP which was repudiated by OP vide letter dated 3.6.2006 on the ground that complainant had been suffering from hypertension and CABG which was pre -existing disease. Alleging deficiency on the part of OP, complainant filed complaint before District Forum. OP resisted complaint and submitted that claim was rightly repudiated on account of pre -existing disease and prayed for dismissal of complaint. Learned District Forum after hearing both the parties, dismissed complaint. Appeal filed complainant was dismissed by learned State Commission vide impugned order against which this revision has been filed along with application for condonation of delay.

HEARD learned Counsel for the parties finally at admission stage and perused record. As there is delay of only 10 days in filing revision petition, delay stands condoned for the reasons mentioned in the application.

LEARNED Counsel for the petitioner submitted that petitioner was having insurance coverage from respondent since last 15 years before angiograph and angioplasty and OP wrongly repudiated claim even then learned District Forum committed error in dismissing complaint and learned State Commission further committed error in dismissing appeal; hence, revision petition be allowed and impugned order be set aside and complaint be allowed. On the other hand, learned Counsel for the respondent submitted that order passed by learned State Commission is in accordance with law; hence, revision petition be dismissed. He further submitted that if petitioner can submit medi -claim insurance coverage since 1990, respondent is ready to reimburse expenses incurred by petitioner in the treatment.

PERUSAL of record reveals that petitioner could not file medi -claim policies from 1990 to November, 2000. Policy covering period of 11.12.2000 to 8.12.2001 reveals that no bonus has been claimed which shows that this was the first policy taken by petitioner. Had petitioner taken earlier policies and not claimed any treatment expenses, he must have been given benefit of no claim bonus. Learned Counsel for the petitioner has placed receipt No.398704 issued on 7.11.1997 by respondent for insurance coverage from 11.11.1997 to 10.11.1998. As per this receipt Mr. S.D. Mehta had deposited premium but this receipt does not contain name of insured and in such circumstances, it cannot be said that complainant deposited this amount for her insurance coverage from November, 1997 to November, 1998. Even if it is presumed to be pertaining to insurance coverage of complainant it is from November, 1997 whereas complainant is claiming insurance coverage from 1990. Learned District Forum rightly observed that complainant was under obligation to produce papers of policy, premium receipt, etc. for the last 15 years.

PERUSAL of discharge summary clearly reveals that CABG to complainant was done in 1992 and complainant was having hypertension since last 12 -13 years as per discharge summary dated 22.12.2004. As per discharge summary dated 8.9.2005, CABG was done before 15 years. Thus, it becomes clear that complainant had history of hypertension and underwent CABG, 15 years before the disputed claim and complainant''s claim fall under pre -existing disease and learned District Forum rightly dismissed complaint in the light of exclusion clause 4.1 which runs as under: "All diseases/injuries which are pre -existing when the cover incepts for the first time".

LEARNED State Commission rightly observed as under: "No documentary evidence was produced before the Forum and a rejoinder was given by the complainant whereby they have stated that the doctor had in discharge card and treatment papers stated that hypertension and CABG was being treated since 15 years by mistake. She should have proved that the doctor is lying by producing affidavit and the case papers submitted by the complaint and the discharge card were for previous treatment and the fact cannot be concealed"

IN the light of above discussion, it becomes clear that on account of pre -existing disease complaint was rightly dismissed by learned District Forum and upheld by learned State Commission, I do not find any illegality, irregularity or jurisdictional error in the impugned order and revision petition is liable to be dismissed.

CONSEQUENTLY , revision petition filed by the petitioner is dismissed at admission stage with no order as to costs.