National Insurance Company Ltd. vs OM PARKASH GOEL

ON a complaint instituted by Om Parkash Goel the District Forum-II ordered that the National Insurance Company Ltd. was liable to pay a sum of Rs. 1,46,350/- spent on account of hospitalisation in the Escorts Heart Institute. Besides this interest @ 12% p.a. and costs Rs. 1,500/- were also awarded on 22.6.1999. Aggrieved against it, the present appeal has been attempted.

BRIEFLY the facts are that Om Parkash Goel is a resident of Panchkula and he was insured for a period of one year on 29.6.1995 for hospitalisation and Domiciliary Hospitalisation Benefit Policy bearing No. 420203/48/37/0031/95 dated 29.6.1995. He paid a premium of Rs. 2,457/- for this purpose. On 6.8.1995, when he was in the market of Sector 9, Panchkula he felt pain in his chest which was unbearable. He was immediately taken to Chawla Nursing and Maternity Home in Sector 9, Panchkula where ECG examination was held and he was advised to proceed to Escorts Heart Institute, New Delhi for Angiography and further treatment. as a consequence thereof he was admitted in the Escort Heart Institute, New Delhi and several tests were carried on 12.8.1995 and thereafter an Open Heart Bye-pass Surgery was conducted in the aforesaid hospital where he incurred an expenditure of Rs. 1,46,350/- but his claim was repudiated by the Insurance Company. The main plea raised on behalf of the appellant is that the complainant concealed his ailment which was pre-existing and got himself insured against the policy referred to above knowingly. It was not a case of sudden ailment. The letter of repudiation dated 24.5.1996 Annexure OP-I is reproduced as under : "Our Ref : 420203/CL/96 Regd. A.D. Date 24.5.1996 Without Prejudice Mr. Om Parkash Goel, H. No. 432, Sec. 15. Panchkula. Reg : Mediclaim No. 48/37/95/02 Pol. No. 420203/48/37/0031/95 Dear Sir, We regret to inform your goodself that the abovesaid claim falls under exclusion "All diseases/injuries which are pre-existing when the cover incepts for the first time". Hence the claim is not in order. Therefore, the Competent Authority has repudiated the liability for the same. This is for your information please. Thanking you, Yours faithfully. Branch Manager"

There is no evidence that the complainant had any heart problem prior to the commencement of the insurance policy. He was neither an outdoor patient nor an indoor patient for any ailment. Dr. Rakesh Soni who opined on the health of the patient on 26.4.1996 Annexure OP-4 has recorded as under : "The claimant had suffered from Myocardial Infarction (Heart Attack) long before 27.7.1995 (Leaf 59)." However, there is no consent evidence that the respondent had any heart ailment or attack earlier or that it was concealed. On our specific enquiry the learned Counsel for the appellant could not point out any evidence to substantiate the plea that Om Parkash Goel-complainant had this ailment earlier or that it was deliberately concealed. In these circumstances we hold that repudiation of the claim was deficiency on the part of the appellant.

THE learned Counsel for the appellant has specifically pointed out that the District Forum-II was not justified in awarding the total amount claimed by the respondents. THE hospitalisation benefits have been specifically enumerated under the head of ''Table of Benefits'' in para No. 9 of the terms and conditions of the insurance policy. THE maximum amount for Board and Nursing expenses has been mentioned as Rs. 16,500/-. Besides this, if the patient is in an ICU unit he shall be entitled to additional sum of Rs. 1,000/-. THE fee of surgeon and anaesthetist has been limited at Rs. 7,000/-. All these have been described in para No. 8 of the Memorandum of Appeal and we have compared it with the table contained in aforesaid insurance policy and we agree with the learned Counsel for the appellant that maximum amount payable was Rs. 60,500/-. Consequently main finding of the District Forum that the appellant was liable and that the repudiation of the claim was a deficiency on the part of the Insurance Company is affirmed but as regards the amount of compensation it is reduced to Rs. 60,500/-, rate of interest and the date from which it shall be paid remains undisturbed. THE costs awarded also reduced to Rs. 1,000/- and with these modifications the appeal stands disposed of. Appeal disposed of with modifications.