New India Assurance Co. Ltd. vs Om Khosla

THIS appeal arises from the order dated 23.8.2003 passed by the District Forum directing the appellant to pay Rs. 1,59,105 towards the mediclaim policy with interest @ 12%.

ADMITTEDLY the respondent insured underwent angioplasty operation in Escorts Heart Institute and remained there from 12.4.1998 to 15.4.1998 and filed a claim of Rs. 1,59,105 towards the actual medical exenses incurred by him but the claim was repudiated by the appellant on the ground that the disease was pre-existing and concealment about this fact disentitled the respondent from claiming mediclaim. We have perused the impugned order and find thatthe claim of the respondent was repudiated mainly on the basis of the report of its panel doctor who formed his opinion on the basis of the record of the Escort Heart Institute. There are two reports of the Escort Heart Institute. One is dated 9th March, 1998 and another is dated 15th April, 1998.According to the panel doctor both these reports contradict each other as on the basis of record dated 9.3.1998 of Escort Heart Insitute "when the respondent was admitted for the first time with complaint of angina on exertion the attending doctor in the clinical summary has mentioned-''has AOE II X 9 years (1989), i.e., TMT test conducted on 9th April, 1989 was positive whereas as per the discharge summary dated 15th April, 1998 the patient had been suffering from angina and dysponia for the last 3-4 years.

Let us assume that both the reports are correct, though according to Dr. Pran Nath these are contradictory. However, District Forum observed that if it was record of two different facts, it was the duty of the panel doctor to obtain copies of TMT report from the Escorts Heart Institute and verify and discuss the matter with the doctors of Escorts Heart Institute.

HOWEVER, we have taken a view that merely because TMT test shows positive as to the angina does not mean that the person at the time of obtaining the mediclaim insurance policy was suffering from such a disease which was pre-existing unless he had been treated for that disease and for which he was subjected to hospitalisation or operation. Had the disease beenof such a nature which was required to be disclosed the respondent should have undergone hospitalisation or operation but merely because some positive signs were shown in the TMT test it cannot be treated as pre-existing disease. These are modern days and a layman is not expected to know and disclose in the proposal form a disease unless and untilhe suffers from such a disease for which he had been hospitalised or undergone operation. In our view the respondent had wronglyrepudiated the claim and further the finding of fact returned by the District Forum needs no interference but we feel inclined to set aside the interest awarded by the District Forumas there was no equitable ground for awarding interest nor was there any term of contract between the parties.

IN the result, we partly allow the appeal by directing the appellant to pay Rs. 1,59,105 towards the actual mediclaim expenses and Rs. 10,000 as compensation and Rs. 5,000 as cost of litigation. Appeal is allowed to the aforesaid extent. A copy of this order as per the statutory requirments, be forwarded to the parties free of charge and also to the concerned District Forum and thereafter the file be consigned to Record Room. Appeal partly allowed.