New India Assurance Co. Ltd. vs LEELA RAMANI

THE opposite party in O.P. No. 1105/98 on the file of the District Consumer Disputes Redressal Forum, Chennai (South) is the appellant herein. THE case of the complainant was as follows : She had taken a mediclaim insurance policy with the appellant/opposite party for herself and her son for the period 24.10.1997 to 23.10.1998 having an insured limit of Rs. 35,000 per head. THE opposite party was bound to compensate any claim made after 30 days from the date of commencement of the insurance cover. THE complainant''s son developed acute pain in the lower back region. It was examined by Dr. Prakash, an Orthopaedic Surgeon who diagnosed the ailment to be an acute prolapsed intervertebral disc. After scanning, the surgeon decided to perform and actually performed an operation on 20.12.1997 at a cost of Rs. 34,208.75. THE complainant submitted a claim before the appellant/opposite party and it was rejected on the ground that their panel Doctor had opined that the patient would have been suffering from the disease for about 6 months prior to operation and, therefore, the claim was not payable as per the policy. Under these circumstances, the complaint came to be filed for the said sum of Rs. 34,208.75 with compensation of Rs. 10,000 and cost of Rs. 5,000.

THE opposite party resisted the complaint on the following grounds. THE claim of the complainant had been rejected for good and valid reasons after obtaining opinion of a panel doctor of the opposite party. THE alleged illness did not require an operation which could be cured by non-operative treatment. THE claim was rejected as the complainant''s son was having a pre-existing disease excluded under the mediclaim policy. THE complainant had to approach the Civil Court for redressal in which case the parties would have adequate opportunities to reject and prove their respective claims. On the side of the complainants Exs. A1 to A9 were marked and on the side of the opposite parties Exs. B1 was marked.

The District Forum accepted the case of the complainant and by order dated 24.1.2002 directed the opposite party to pay Rs. 34,208.75 together with a compensation of Rs. 10,000 for mental agony and cost of Rs. 1,000 granting a month''s time for payment. It is as against that the present appeal has been filed.

ON the side of the appellant/opposite party learned Counsel submitted that as per exclusion 4(1) of the terms and conditions of the policy pertaining to the policy of insurance, the rejection had been done, that the exclusion clause had been provided in the contract of insurance so as to prevent persons from taking undue advantage of the policy by taking a mediclaim after coming to know that they suffered from certain diseases. According to Counsel, the complainant had taken the policy on 24.10.1997 and her son developed acute pain on 11.12.1997; the doctor diagnosed ailment to be prolapsed intervertebral disc, and after scanning on 18.12.1997 performed the operation on 20.12.1997; the opinion of the complainant''s surgeon in his letter dated 25.3.1998 was make believe and could not stand medical scrutiny; by no stretch of imagination, could it be said that the nature of the ailment of the complainant''s son could occur suddenly and on a single day as the disease was progressive in nature and would not occur overnight to necessitate the performance of a surgery. The learned Counsel relied on the opinion of the opposite party''s panel Doctor which was given on 28.1.1999. As per the panel doctor''s opinion, Disc Prolapse was usually given an initial therapy of non-operative treatment in the form of Pelvic traction etc., which could extend for a period of six months. Immediate surgery was resorted to only in the case of massive disc prolapse where there was loss of bladder control that in the instant case the scan did not show a massive disc prolapse nor did the clinical features suggest bladder involvement, that the panel doctor presumed that the disease was about six months old. In such circumstances, according to learned Counsel, the District Forum was in error in accepting the case of the complainant and granting relief. In the submission of the learned Counsel, the remedy if any of the complainant was to approach the Civil Court for redress of her so called grievance in which case, the parties would have adequate opportunity to project and prove their respective cases and points by examining experts in the field. We need not got into details of the submissions for the following simple preason. The complainant''s son was operated on 20.12.1997. The opposite party rejected the claim by letter dated 10.6.1998. On 10.6.1998, the opposite party had not obtained any information from the panel doctor, because the opinion of the panel doctor is dated 28.1.1999 (Ex. B1). It is also interesting to note that the concluding part of the opinion reads as ''based on the above, you may prepare defence'' which shows as rightly pointed out by the District Forum that the defence of the opposite party had been prepared after the opinion of the doctor which was given on 28.1.1999. The complaint came to be filed on 26.11.1998 and taken on file on 21.12.1998. The rejection as already noted was even on 10.6.1998. Expert opinion was obtained after the filing of the complaint. The opposite party was totally lacking in bona fides and we are convinced that their only object was to defeat the claim of the complainant. We are satisfied that the District Forum had rightly granted the relief to the complainant and no exception can be taken to the same. We do not find any merit in the appeal.

IN fine, the appeal fails and the same is dismissed with a cost of Rs. 1,500. Appeal dismissed.