MANJIT KAUR vs NEW INDIA ASSURANCE CO. LTD.

AFTER hearing the learned Counsel for the appellant, namely Mr. Virinder Kumar Shukla, Advocate and going through the impugned order of the District Consumer Disputes Redressal Forum-II, U.T. Chandigarh (for short hereinafter referred to as the District Forum) dated 2.4.2003 dismissing the Complaint Case No. 667 of 2000, we find that there is no merit in this appeal and it deserves to be dismissed in limine. The reasons for our view are as under :

THE appellant/complainant took a Medi-Claim Policy (Copy Annexure P-2) which covered the risk for the period from 1.7.1997 to 30.6.1998. No claim was preferred during this period and she took another policy i.e. Medi-Claim Policy dated 8.8.1998 (Copy Annexure P-1) for the period from 1.7.1998 to 30.6.1999 and paid its premium of Rs. 2,090/-. After taking this policy, the appellant suffered from pain in the abdomen and was admitted in the PGIMER, Chandigarh. THE diagnoses of the disease was cholelithiasis. She was to be operated by the consultant Dr. J.D. Wig. THE surgery was done on 18.3.1999 and the complainant was discharged on 21.3.1999. THE photocopy of the Discharge Slip issued by the PGIMER, Chandigarh was filed as Annexure R-2 by the respondents which contains the clinical history about the patient and shows that she had heaviness of abdomen, flatulent dyspepsia for the last 3 years. She had pain of abdomen - lepisode of moderate to severe pain - 3 years back, not radiating to back, managed conservatively h/o mild pain in right hypochondrium since then, managed with analgesics - No h/o jaundice/fever with chills/rigors stools (normal), urine (normal). This clinical history was evidently noted in the Discharge Card on the basis of the information furnished either by the patient or her companions and it clearly shows that she had the problem relating to her gall bladder at least three years; prior to her date of admission in the PGIMER, Chandigarh i.e. 16.3.1999 which included the period of Medi-Claim Policy of Insurance i.e. 1.7.1998 to 30.6.1999.

In Clauses 4.0 and 4.1 of the Medi-Claim Policy (Photocopy Annexure R-3), there are exclusionary clauses. A combined reading of Clauses 4.0 and 4.1 showed that the Company was not liable to make any payment under the Medi-Claim Policy in respect of any expenses incurred by insured person in connection with or in respect of such diseases which had been pre-existing at the time of proposing the insurance. Pre-existing condition also means any sickness or its symptoms which existed prior to the effective date of this insurance, whether or not the insured person had knowledge that the symptoms were relating to the sickness complications arising from pre-existing disease will be considered part of that pre-existing conditions.

THE Insurance Company made inquiries from one Dr. K. Baskeran, M.D. who gave his opinion. Dr. Baskeran is on the panel of the Insurance Company. Even if the opinion of Dr. Baskeran be not taken into consideration, even then the Discharge Card (Photocopy Annexure R-2) which is in respect of the treatment of the appellant herself, clearly shows that she had the problem of abdominal pain, heaviness of abdomen, flatulent dyspepsia for the last three years from the date of admission and if same is considered under the exclusionary Clauses 4.0 and 4.1, referred to above, the complainant cannot say that she was not in the know of the disease for which she got herself admitted for treatment in PGIMER, Chandigarh on 16.3.1999 and after surgery on 18.3.1999, she was discharged on 22.3.1999. It is important to note that regarding Clause 4.1 of the Medi-Claim Policy of Insurance, the knowledge of the insured is not an important condition, inasmuch as Clause 4.0 of the policy reads, inter alia, "........ Pre-existing condition also means any sickness or its symptoms which existed prior to the effective date of this insurance, whether or not the insured person had knowledge that the symptoms were relating to the sickness complications arising from pre-existing disease will be considered part of that pre-existing condition". (Emphasis laid by us)

IN our considered opinion, the District Forum has rightly held that the claim of the appellant/complainant was duly covered under the exclusionary Clauses 4.0 and 4.1 and as such she could not get her claim under the Medi-Claim Policy. The complaint was rightly dismissed. The appeal is dismissed in limine. Copies of this order be sent to the parties free of charge. Appeal dismissed.